Future Sight Loss UK 1 - Full Report - RNIB · Web viewThe economic impact of partial sight and blindness in the UK adult population Contents Executive summary 1. Background 1.1 Definitions

The economic impact of partial sight and blindness in the UK adult population

ContentsExecutive summary1. Background1.1 Definitions of partial sight and blindness1.2 Conditions leading to partial sight and blindness2. Prevalence of partial sight and blindness2.1 Population data2.2 Prevalence rates by age, gender, ethnicity, severity and major region2.3 Prevalence of partial sight and blindness in the UK2.4 Projections of prevalence to 20503. Health care system expenditure3.1 Hospital recurrent expenditure3.2 Non-admitted expenditure3.3 Prescribing expenditure in primary care3.4 General ophthalmic services3.5 Expenditure associated with injurious falls3.6 Research and development3.7 Residential care and community care sectors3.8 Capital and Administration3.9 Summary of health care system expenditure4. Indirect costs4.1 Productivity losses4.2 Informal care costs4.3 Devices and modifications4.4 Deadweight loss4.5 Summary of indirect costs5. Burden of disease5.1 Methods used for measuring and valuing the burden of disease5.2 Burden of disease from partial sight and blindness6. Projection of health care system costs and indirect costs7. International comparisons8. Case studies8.1 Promote the prevention of eye injuries8.2 Improved access to integrated low vision and rehabilitation services

Logo – RNIB supporting blind and partially sighted peopleRegistered charity number 226227

8.3 Regular eye tests for the older population8.4 Improved access to eye care services for minority ethnic groups9. Conclusions10. Appendix A11. References

FiguresFigure 2-1: Age distribution of projected minority ethnic population in the UK, 2008Figure 3-1: Proportion of recurrent hospital expenditure in England, by condition 2008Figure 3-2: Breakdown of non-commercial UK health research funding, 2003-04Figure 5-1: Share of the burden of disease across conditions 2008Figure 5-2: Burden of disease across conditions, by severity of sight loss, 2008Figure 6-1: Projected total costs due to partial sight and blindness in the UKFigure 8-1: Proportion of eye injury presented to A&E, by activityFigure 8-2: Distribution of benefit/cost ratio from campaign to reduce eye injuriesFigure 8-3: Proportion of low vision appointments offered by provider type

TablesTable 1-1: Summary of costs associated with partial sight and blindness in UK adults 2008Table 2-1: Projected regional population by ethnicity, 2008Table 2-2: Projected UK country population by ethnicity, 2008Table 2-3: Projected UK country population by ethnicity, 2010-2050Table 2-4: Prevalence of partial sight and blindness for the UK population 75 years and older (binocular visual acuity <6/18)Table 2-5: Causes of Partial sight and blindness (binocular visual acuity <6/18)Table 2-6: Causes of partial sight and blindness by age and sex (binocular visual acuity <6/18)Table 2-7: Causes of partial sight and blindness (binocular visual acuity <6/18)Table 2-8: Partial sight and blindness prevalence ( per cent) by age, gender, cause & severity (75+)Table 2-9: Partial sight and blindness prevalence ( per cent) by age, gender, cause & severity (55-74)Table 2-10: Partial sight and blindness prevalence ( per cent) by age, gender, cause & severity (<55)

Table 2-11: Relative risk of selected eye diseases due to ethnicityTable 2-12: Summary of prevalence sourcesTable 2-13: Partial sight and blindness (<6/12) by age, gender & disease type, UK (people) 2008Table 2-14: Blindness (<6/60) by age, gender & disease type, UK (people) 2008Table 2-15: Partial sight and blindness by age, gender & severity, UK (people) 2008Table 2-16: Partial sight and blindness (<6/12) by age, gender & ethnicity, UK (people) 2008Table 2-17: Projection of partial sight and blindness (<6/12) by gender & ethnicity UK (people)Table 2-18: Projection of partial sight and blindness (<6/12) by disease type, UK (people), 2010 to 2050Table 3-1: Hospital recurrent expenditure associated with partial sight and blindness in England 2008Table 3-2: Hospital recurrent expenditure in devolved countries 2008Table 3-3: Hospital recurrent expenditure in the UK 2008Table 3-4: Private hospital expenditure in the UK related to partial sight and blindness 2008Table 3-5: Outpatient costs for England 2008Table 3-6: Other outpatient services costs for England, by service type 2008Table 3-7: Other outpatient services costs for England, by condition 2008Table 3-8: Outpatient and other community services NHS expenditure for the UK 2008Table 3-9: Outpatient and other community services private expenditure for the UK 2008Table 3-10: Community eye prescription expenditure for England 2008Table 3-11: Community eye prescription expenditure for England, by condition 2008Table 3-12: Public expenditure for prescribing within primary care 2008Table 3-13: Public GOS Expenditure on persons ≥18 years of age 2008Table 3-14: Number of eye tests in Scotland, by condition, 2007-08Table 3-15: Public GOS expenditure on people ≥18 years of age, by condition 2008Table 3-16: Private GOS Expenditure by persons ≥18 years of age 2008Table 3-17: Odds ratio of falls and hip fractures due to sight lossTable 3-18: Prevalence of depression in those with sight lossTable 3-19: Number of-episodes related to falls for total UK population, 2006-07Table 3-20: Estimated episodes related to falls due to partial sight and blindness in the UK 2008

Table 3-21: Public cost of episodes related to falls due to partial sight and blindness in the UK 2008Table 3-22: BBSRC R&D expenditure 2008Table 3-23: DALYs for sense organ diseases, by cause and gender, 2001Table 3-24: Breakdown of non-commercial UK health research funding 2008Table 3-25: Expenditure on social services for adults with physical disability and older people in England, 2006-07Table 3-26: Estimated expenditure on community services for those with sight loss in England 2008Table 3-27: Estimated expenditure on community services for those with sight loss, Devolved Nations 2008Table 3-28: Summary of health care system expenditure, by country 2008Table 3-29: Summary of health care system expenditure, by condition 2008Table 4-1: Employment rates, by level of seeing difficulty 2007Table 4-2: Employment gap and median gross income for those with sight loss 2008Table 4-3: Productivity loss due to partial sight and blindness 2008Table 4-4: Productivity loss due to absent days resulting from partial sight and blindness 2008Table 4-5: Cost of premature mortality from partial sight and blindness 2008Table 4-6: Number of informal carers in the UK by age, sex and hours spent providing care, 2006-07Table 4-7: Number of informal carers in the UK providing care to those with partial sight and blindness, 2008Table 4-8: Total direct payments to people with sight loss and informal carers, by direct payment type 2008Table 4-9: Summary of indirect costs 2008Table 5-1: DALYs associated with disability from partial sight and blindness in the UK 2008Table 5-2: Estimated number of deaths due to sight loss 2008Table 6-1: Projected health care system costs due to partial sight and blindness in the UKTable 6-2: Projected indirect costs due to partial sight and blindness in the UKTable 7-1: International comparison of the economic cost of partial sight and blindnessTable 8-1: Estimated Number of eye injuries in the UK workplaceTable 8-2: Estimated A&E visits, hospitalisations, and severity of eye injury, 2007-08Table 8-3: Estimated NHS costs due to eye injury 2008Table 8-4: Estimated benefits from an educational program to avoid eye injuryTable 8-5: Inputs varied in the Monte Carlo simulation

Table 8-6: Types of services receivedTable 8-7: Professionals consulted in the year after registrationTable 8-8: Cost of additional Low Vision Services 2008Table 8-9: Reduction in DALYs per year due to the campaign 2008Table 8-10: Inputs varied in the Monte Carlo simulationTable 8-11: People with partial sight and blindness not in touch with eye care services 2008Table 8-12: Prevalence of undetected mild sight loss (<6/12 to 6/18) in the UK 2008Table 8-13: Frequency of eye tests, by ageTable 8-14: Number of sight tests for the older population in the UK, 2008Table 8-15: Sight test fee in England, Wales and Northern IrelandTable 8-16: Sight test fees in ScotlandTable 8-17: Estimated cost of additional treatment 2008Table 8-18: Estimated total cost of a campaign to increase sight tests 2008Table 8-19: Inputs varied in the Monte Carlo simulationTable 8-20: Estimated prevalence of undetected partial sight in MEGs in the UK 2008Table 8-21: DALYs avoided through corrected vision as a result of the campaignTable 8-22: Estimated reduction in DALYs from avoiding further reduction in partial sight in MEGsTable 8-23: Estimated cost of additional treatment to MEGsTable 8-24: Total cost of a campaign to increase MEG eye care accessTable 8-25: Inputs varied in the Monte Carlo simulation

Glossary of AcronymsAMD: age-related macular degenerationCPI: consumer price index (a measure of inflation)DALY: disability adjusted life yearDoH: Department of Health DR: diabetic retinopathyFY: financial year GDP: gross domestic productHSE: Health and Safety ExecutiveMEGs: minority ethnic groupsMVIP: Melbourne Visual Impairment ProjectQALY: quality adjusted life yearRE: refractive errorRNIB: Royal National Institute of Blind peopleVSL(Y): value of a statistical life (year)WHO: World Health Organization

WTP: willingness to payYLD: years of healthy life lost due to disabilityYLL: years of life lost due to premature mortality

AcknowledgementsAccess Economics would like to acknowledge with appreciation the insightful comments received on previous drafts of this report from the Expert Advisory Group and EpiVision, including Jennifer Beecham, Parul Desai, Alistair Fielder, Anita Lightstone, David Lye, Barbara McLaughlan, Pritti Mehta, Darwin Minassian (EpiVision), John Ravenscroft, Angela Reidy (EpiVision) and Steve Winyard.

Executive SummaryAccess Economics (Australia) was commissioned by the Royal National Institute of Blind People (RNIB) to estimate the economic impact of partial sight and blindness in the UK adult population, including the direct and indirect costs of partial sight and blindness, and the burden of partial sight and blindness on health. In addition, Access Economics was asked to undertake an international comparison (Australia, US, Japan, and Canada) and several cost effectiveness analyses on strategic interventions that are expected to prevent and ameliorate the impact of sight loss in the UK adult population.

The economic costs presented in this report relate to the adult UK population (18 years of age or over). Although prevalence of partial sight and blindness has been estimated and reported for those aged 0 to 39, these data must be used with caution. Data on the prevalence of childhood partial sight and blindness in the UK is limited and variable. More research needs to be undertaken into measuring childhood partial sight and blindness and the associated economic costs within the UK.

This report comprises the following estimates: prevalence of partial sight and blindness in the UK by age, gender,

ethnicity, severity, major region and major cause in 2008, and future projections by decade to the year 2050;

the direct health system costs of partial sight and blindness in the UK adult population, disaggregated by cost components (hospital, non-admitted, prescribing in primary care, ophthalmic services, research and development, residential care and community care, capital and administration) for the year 2008;

the indirect costs of partial sight and blindness in the UK adult population, disaggregated by cost components (including productivity losses, informal care costs, devices and modifications, and the tax inefficiencies associated with transfer payments and public funding of health care) for the year 2008;

the burden of disease, measured in terms of disability adjusted life years (DALYs), of partial sight and blindness in the UK adult population, disaggregated by years of life lost due to premature death (YLL) and healthy years of life lost due to disability (YLD), and converted into a reasonable monetary equivalent;

projection of health care system costs and indirect costs for 2009 to 2013; a comparison with other countries – Australia, US, Canada and Japan;

and

economic evaluation of four hypothetical eye care programs to inform recommendations for rational, cost-effective service delivery, development and improvement in policy and practice.

The results of the study indicate that partial sight and blindness in the adult population places a large economic cost on the UK, totalling £22.0 billion in 2008. Direct health care system costs amount to £2.14 billion and indirect costs amount to £4.34 billion. In addition, the loss of healthy life and the loss of life due to premature death associated with partial sight and blindness also impose a cost on society through a reduction in the stock of health capital. This reduction was estimated at £15.51 billion in 2008. A detailed breakdown of direct and indirect costs, and the reduction in the stock of health capital associated with the burden of disease is shown in Table 1-1.

Table 1-1: Summary of costs associated with partial sight and blindness in UK adults 2008Direct costs £ millionHospital recurrent expenditure 592.74Non-admitted expenditure 507.99Prescribing expenditure 158.12General ophthalmic services (GOS) 484.04Expenditure associated with injurious falls 25.10Research and development 13.99Residential care and community care services

304.69

Capital and administration 58.22Total – Direct costs 2,144.89Indirect costsLower employment 1626.70Absenteeism 79.85Premature mortality 2.38Informal care costs 2,029.70Devices and modifications 336.50Deadweight loss 268.59Total – Indirect costs 4,343.72Burden of disease costsYears of life lost due to morbidity 14,530.67Years of life lost due to premature death 978.43Total – Burden of disease costs 15,509.10Total –Costs 21,997.71Source: Access Economics calculations

In addition to estimating the economic cost of partial sight and blindness in the UK adult population, four hypothetical eye care interventions were evaluated to estimate their potential cost effectiveness. These focused on four areas that have been identified as most relevant for current policy, and include: promote the prevention of eye injuries; improve access to integrated low vision and rehabilitation services; increase regular eye tests for the older population (≥ 60 years); and increase access to eye care services for minority ethnic groups (MEGs).

The results show that the most effective campaign is expected to be one that focuses on MEGs. This is because their access to eye care services is lower than the average population and their undetected eye conditions are more likely to be severe. It was estimated that an educational campaign using media and an educational road show to ten locations heavily populated with MEGs throughout the UK could result in a cost effectiveness ratio of £1,230 per DALY avoided (90 per cent confidence interval of £1,032 per DALY avoided to £1,559 per DALY avoided).

Results of the other three economic evaluations show there are gains to be made in investing in the promotion of eye care services. In summary the results indicated the following. A cost effectiveness ratio of £24,200 per DALY avoided for a campaign

that targets older people (≥60 years) to take up regular eye examinations (90 per cent confidence interval of £17,000 per DALY avoided to £41,200 per DALY avoided).

A cost effectiveness ratio of £100,857 per DALY avoided for a campaign that encourages those with recognised partial sight and blindness to use low vision services (90 per cent confidence interval of £73,900 per DALY avoided to £152,900 per DALY avoided).

A benefit/cost ratio of 1.62 for a campaign that promotes the use of eye protection to avoid eye injuries (90 per cent confidence interval of 1.32 to 2.25).

1. BackgroundAccess Economics was commissioned by the Royal National Institute of Blind People (RNIB) to undertake an economic impact analysis estimating the prevalence, direct and indirect costs, and burden of disease associated with partial sight and blindness in the UK adult population.

The methodology used in this study builds on the successful costing and burden of disease methodologies developed by Access Economics and applied in Australia and internationally, using data from a number of UK and international epidemiological studies, UK census materials and official population projections, NHS inpatient and outpatient cost data, UK and devolved nations government publications, and a variety of other studies and peer reviewed journal articles that have investigated the costs associated with partial sight and blindness.

The report is structured as follows. Chapter 2 estimates prevalence of partial sight and blindness in the UK

adult population by age, gender, ethnicity, severity, major region and major cause in 2008, and provides future projections by decade to the year 2050.

Chapter 3 presents the direct health care system costs of partial sight and blindness in the UK, disaggregated by cost components (hospital, non-admitted, prescribing in primary care, ophthalmic services, research and development, residential care and community care, capital and administration) for the year 2008.

Chapter 4 calculates the indirect costs of partial sight and blindness in the UK, disaggregated by cost components (including productivity losses, informal care costs, community care costs, and the deadweight losses associated with transfer payments), for the year 2008.

Chapter 5 estimates the burden of disease of partial sight and blindness in the UK, measured in terms of disability adjusted life years (DALYs), disaggregated by years of life lost due to premature death (YLL) and healthy years of life lost due to disability (YLD), and converted into a monetary equivalent for the year 2008.

Chapter 6 provides projections of direct health care system costs and indirect costs associated with sight loss between 2009 and 2013.

Chapter 7 summarises the costs of partial sight and blindness in the UK and compares the findings in the UK with findings from Australia, the United States, Canada and Japan.

Chapter 8 presents a number of economic evaluations of hypothetical strategic preventions to prevent and ameliorate the impact of sight loss in the UK.

Chapter 9 provides conclusions.

All monetary values presented in this report are in Sterling and 2008 prices, unless otherwise stated. All costs in this report have been converted to 2008 prices using the consumer price index (CPI) derived from http://www.statistics.gov.uk/statbase/tsdataset.asp?vlnk=7174&More=N&All=Y (accessed 15 February 2009).

1.1 Definitions of partial sight and blindnessPartial sight and blindness can be broadly defined as a limitation in one or more functions of the eye or visual system, most commonly impairment of visual acuity (sharpness or clarity of vision), visual fields (the ability to detect objects to either side or above or below the direction in which the person is looking), contrast sensitivity and colour vision.

Normal vision is recorded as 20/20 in Imperial measures (6/6 in metric), which means that a person can see at 20 feet (6 metres) what a person with normal vision can see at 20 feet. Degrees of partial sight and blindness are measured similarly, where the first number in the measure is the furthermost distance at which the person can clearly see an object and the second number is the distance at which a person with normal vision could see the same object. For example, 20/40 vision means that the person can clearly see at 20 feet (but not more) an object that a person with normal vision could see at 40 feet (but not more).

Partial sight and blindness can differ from one eye to the other (when vision remains good in one eye). As a result, prevalence rates can be reported for either the better or the worse eye in terms of the extent of sight loss. Asymmetrical sight loss, however, has little impact on function or disability and indeed, the visual function is determined by the vision of the better eye, and often it is only when sight loss becomes bilateral that it is identified and treated.

When reporting prevalence rates, better eye measures would provide conservative estimates while worse eye measures may tend to overstate sight loss and costs. In this study, the conservative approach has been adopted to report partial sight and blindness prevalence for the better eye.Common definitions for visual acuity used in the UK and in this report are as follows:

Blindness (severe sight loss) is defined as best-corrected visual acuity of <6/60 in the better-seeing eye.

Partial sight is defined as best-corrected visual acuity of <6/12 to 6/60 in the better-seeing eye, and is categorised as:

1 mild sight loss – best-corrected visual acuity of <6/12 but better than or equal to 6/18; and

2 moderate sight loss – best-corrected visual acuity of <6/18 but better than or equal to 6/60.

Sight loss is defined as partial sight or blindness in the better-seeing eye.

1.2 Conditions leading to partial sight and blindnessWithin this study five leading causes of partial sight and blindness were investigated, including age-related macular degeneration (AMD), cataract, diabetic retinopathy, glaucoma, and refractive error. The prevalence of partial sight and blindness from all other causes was also calculated as the residual from total partial sight and blindness minus the five leading causes of partial sight and blindness.

1.2.1 Age-related Macular Degeneration (AMD)AMD is an incurable eye disease and a leading cause of blindness in elderly people in developed economies. AMD occurs with degeneration of the macula, which is the part of the retina that enables central vision and seeing fine detail. Damage to the macula is characterised by central vision loss.

In “early AMD,” small yellow deposits called drusen form under the macula. Vision is usually lost with more advanced stages of AMD. There are two types of “late AMD”: Dry (geographic/atrophic): In around one third of cases of late AMD, the

macula thins. Vision loss is directly related to the location and amount of retinal thinning, but the progress of dry AMD is slower than that of the “wet” type. There is no known treatment or cure for the “dry” type of AMD.

Wet (exudative/neovascular): Two thirds of those with late AMD have this type. Abnormal blood vessels grow under the retina and macula; these vessels bleed and leak fluid, causing the macula to bulge or lift up. Vision loss may be rapid and severe. Thermal laser surgery may be used in the early stages and may retard severe eye damage for some patients, but does not preclude reoccurrence, so that at best it slows the rate of vision loss.

Risks of AMD include smoking, age and a genetic component, with family history increasing the risk of AMD three to four times – in fact genetic factors now explain around 75 per cent of AMD. In most cases there is no effective

prevention of, or treatment for, AMD. Because AMD is painless, usually progressing slowly and generally in one eye first, it may be difficult to self detect in the initial stages (Access Economics, 2006).

1.2.2 CataractA cataract is a clouding of the eye's natural lens. The lens is mostly made of water and protein and the protein is arranged in a precise way that keeps the lens clear and allows light to pass through it. However, some of the protein may clump together and start to scatter light and cloud a small area of the lens forming a cataract. Over time, the cataract may grow larger and cloud more of the lens, making it hard to see. The most common symptoms are blurry vision, problems with light, ‘faded’ colours, double or multiple vision and the need for frequent changes in glasses or contact lenses.

The four main types of cataract are age-related (most common), congenital, secondary (following intravascular inflammation systemic disease or steroid use) and traumatic (e.g., due to eye injury). Causes of age-related cataract include hereditary factors, age, smoking, diabetes and ultraviolet (UV) exposure. Detection is through an eye examination including a visual acuity test (eye chart test) and pupil dilation (where the pupil is widened with eye drops to allow the eye care professional to see more of the lens and look for other eye problems).

Cataract surgery may be recommended to improve vision, with the cloudy lens removed and replaced with a substitute lens. Surgery is safe and very effective, with almost all people having better vision and improved quality of life afterward, and only a small percentage experiencing complications such as infection, bleeding or inflammation. Cataract surgery is generally performed as same-day surgery without general anaesthetic, with a six week total recovery period.

1.2.3 Diabetic retinopathyDiabetic retinopathy (DR) is a complication of diabetes mellitus, usually affecting both eyes, wherein microaneurysms develop on the tiny blood vessels inside the retina. As the disease progresses, some blood vessels that nourish the retina are blocked, causing vision loss through either proliferative retinopathy or macular edema.

DR often has no early symptoms. Sometimes the person sees specks of blood, or spots, "floating" in their vision. Diagnosis can be made via a visual acuity test (eye chart test), dilated eye examination, retinal photography and/or fluorescein angiogram. Macular edema is treated with focal laser

surgery, which stabilizes vision and reduces the risk of vision loss by 50 per cent. Newer anti-VEGF therapies are also being used.

Proliferative retinopathy is retarded with peripheral scatter laser surgery (pan-retinal photocoagulation) that, while it can worsen peripheral, colour and/or night vision, can save the rest of a person’s sight. If bleeding is severe and persistent, a vitrectomy may be necessary, where blood and gel are removed from the centre of the eye and replaced with a salt solution, under local or general anaesthetic.

Although both laser treatment and vitrectomy can effectively retard vision loss they do not cure DR, and the patient remains at risk for new bleeding. Multiple treatments may be necessary.

People with diabetes can prevent the onset and progression of DR (and the need for surgery) by controlling their levels of blood sugar, blood pressure and blood cholesterol. Early diagnosis and treatment can prevent up to 98 per cent of severe vision loss (Access Economics 2004) and the earlier treatment is received the more likely it is to be effective.

1.2.4 GlaucomaGlaucoma is a group of diseases that, while initially asymptomatic, can damage the eye's optic nerve and result in blindness. The optic nerve comprises nerve fibres that connect the retina with the brain. In the front of the eye is a space called the anterior chamber – clear fluid flows in and out of this space, leaving the chamber at the angle where the cornea and iris meet. When the fluid reaches the angle, it flows through a spongy meshwork, like a drain, and leaves the eye.

Primary open-angle glaucoma, the most common type, occurs when, for unknown reasons, the fluid passes too slowly through the meshwork drain. As the fluid builds up, the pressure inside the eye rises. Unless the pressure at the front of the eye is controlled, it can lead to damage of the optic nerve and cause vision loss. Although people can see objects clearly in front of them, they miss things to the side and out of the corner of their eye. Peripheral vision may deteriorate without treatment, like looking through a tunnel, until there is no vision left. Other less common types of glaucoma include the following: Closed-angle glaucoma, in which the fluid at the front of the eye is

blocked from reaching the angle, resulting in a sudden increase in pressure, pain, redness and blurred vision. Immediate (medical emergency) laser surgery is required to clear the blockage and protect sight.

Congenital glaucoma, occurring in children born with defects in the angle of the eye that slow fluid drainage, causing cloudy eyes, sensitivity to light and excessive tearing. Prompt surgery provides an excellent chance of saving vision.

Secondary glaucoma, which develops as a complication of other medical conditions, such as surgery, advanced cataract, eye injuries, certain eye tumours, uveitis (eye inflammation), diabetes or the use of corticosteroid drugs. Treatment includes medicines and laser or conventional surgery.

Increased risk for glaucoma occurs with age, family history and race. Glaucoma is detected through an eye examination including visual acuity, visual field, tonometry and optic nerve examination. Although there is no cure for glaucoma, early diagnosis and treatment may help protect eyes against serious vision loss and blindness. Some of these include the following: Medicine (very common) – eye drops and/or pills taken several times a

day can lower pressure by helping fluid drain from the eye or causing the eye to make less fluid. Rare side effects include headaches or eye irritation.

Laser surgery (laser trabeculoplasty) – helps fluid drain from the eye by burning holes in the meshwork with a high-energy light beam. The effects of laser surgery wear off so that, after two years, the pressure increases again in more than half of all patients. Repeating laser surgery is often not useful.

Filtration surgery – can make a new opening for the fluid to leave the eye. Such surgeries are often performed after medicine and laser surgery have failed to control pressure. Surgery is around 80 to 90 per cent effective at lowering pressure. However, if the new drainage opening closes, a second operation may be needed. Conventional surgery works best in the absence of other previous eye surgery.

Possible side effects of glaucoma surgery include cataract, inflammation or infection inside the eye, and swelling of blood vessels behind the eye – all of which are treatable. In some cases, vision may worsen after surgery.

1.2.5 Refractive errorIt is important to distinguish between sight loss caused by under-corrected refractive error that is easily reversed with the appropriate correction (spectacles or contact lenses) and sight loss from pathologic myopia. Under-corrected refractive errors (such as myopia and hyperopia) occur

when optical defects result in light not focusing properly on the retina. In most cases this sight loss due to refractive error can be easily corrected by eye glasses or contact lenses.

Pathologic myopia is quite different from uncorrected myopia. Pathologic myopia occurs in extreme short-sightedness that is associated with major lengthening and elongation of the eyeball. This is associated with degenerative changes in the macula and at times with retinal detachment. Each of these changes can result in profound sight loss (including blindness) that will not be corrected with refraction.

1.2.6 Other causes of vision lossLess common conditions such as neuro-ophthalmic disorders (main disorders in children), retinitis pigmentosa and other retinal conditions account for the remaining prevalence of partial sight and blindness.

2. Prevalence of partial sight and blindness The costing methodology used in this study is based on a prevalence approach to cost measurement, as the data sources lend themselves to utilisation of such an approach. This methodology also avoids the uncertainty surrounding estimates of future treatment costs associated with an incidence approach.

Prevalence approaches measure the number of people with a given condition (in this case partial sight and blindness) in a base period (in this case calendar year 2008) and the costs associated with treating them, as well as other financial and non-financial costs (productivity losses, carer burden, loss of quality of life) in that year, due to the condition.

In this study, prevalence of partial sight and blindness was calculated by multiplying population data by prevalence rates for the six key causes of partial sight and blindness (age-related macular degeneration (AMD), cataract, diabetic retinopathy (DR), glaucoma, refractive error, and other). This was stratified by age, gender, ethnicity, severity. An overview of the methodology used to construct and project the population data is provided below, along with an overview of the prevalence rates for each major condition.

2.1 Population dataPopulation estimates for England regions, UK countries and the total UK population were required for 2008, split by five-year age cohorts, gender and five ethnic groups – White, Black, Asian, Mixed and Other. Population projections for the total UK population were also required for 2010, 2020, 2030, 2040 and 2050.

2.1.1 England regionsPopulation by age cohorts, ethnicity and gender was estimated for nine England regions up to 2008. The regions comprised: North East; North West; Yorkshire and Humberside; East Midlands; West Midlands; East; South East; South West; and

London.Total population for each region by age cohorts and gender for 2008 were derived from 2006-based sub-national population projections for government office regions developed by the Office of National Statistics (ONS). As these projections only relate to the total population they were split by ethnicity to meet the needs of this study.

Although the 2007 Labour Force Survey (ONS, 2008) encompasses the most recent population measurement by ethnicity and age for each region, it only breaks age down into four age cohorts (16-19, 20-24, 25-49, and 50+) and does not split by gender. Consequently this dataset could not be used.

Instead, ethnicity population by five year age cohorts and gender for each region were derived from the 2001 Census. Ethnic proportions for each region were applied to the total population projections for 2008. This method implicitly assumes that the composition of ethnicity within each region has not changed significantly between 2001 and 2008, which is clearly not the case for some regions. However it is not expected that the changes will have a significant impact on the final partial sight and blindness results. Table 2-1 shows the projected regional population by ethnicity for 2008.

Projected regional population by ethnicity, 2008. Figures in thousands.Table 2-1

White Black Asian Mixed Other Total

North East

2,507.9 4.0 33.9 12.2 10.5 2,568.5

North West

6,258.8 42.5 235.7 62.6 41.6 6,911.2

Yorkshire 4,890.7 35.9 235.3 46.2 23.4 5,231.6East Midlands

4,163.4 41.9 179.7 44.6 21.8 4,451.3

West Midlands

4,812.8 106.0 394.2 73.2 31.1 5,417.4

East 5,439.2 50.7 128.2 60.1 36.9 5,715.1London 5,423.6 830.4 922.4 237.5 206.5 7,620.5South East

7,949.8 58.7 193.3 87.9 64.9 8,354.6

South West

5,098.9 22.0 34.6 38.6 23.3 5,217.5

Figures as a percentageTable 2-1


North East

97.6 0.2 1.3 0.5 0.4 100.0

North West

94.5 0.6 3.4 0.9 0.6 100.0

Yorkshire 93.5 0.7 4.5 0.9 0.4 100.0East Midlands

93.5 0.9 4.0 1.0 0.5 100.0

West Midlands

88.8 2.0 7.3 1.4 0.6 100.0

East 95.2 0.9 2.2 1.1 0.6 100.0London 71.2 10.9 12.1 3.1 2.7 100.0South East

95.2 0.7 2.3 1.1 0.8 100.0

South West

97.7 0.4 0.7 0.7 0.4 100.0

Source: Access Economics calculations.

2.1.2 Devolved nationsPopulation for 2008 by age cohorts, ethnicity and gender were estimated for the four UK countries – England, Scotland, Northern Ireland and Wales. As with the English regions, total population estimates for 2008 were derived from the 2006-based sub-national population projections for government office regions developed by the ONS and needed to be split by ethnicity.

Ethnic population estimates for England and its regions were calculated from the ONS 2005 experimental population estimates. However, these experimental population estimates do not cover Scotland, Northern Ireland or Wales, so alternative ethnic splits across five year age cohorts and gender were sought.

Ethnic splits by five year age cohorts and gender for Scotland and Wales were derived directly from the 2001 census, which were applied to the total population projections for 2008.

Although total ethnic populations were available for Northern Ireland from the 2001 census, ethnic splits by five year age cohorts or gender were not. Consequently, the ethnic age and gender profile for England was applied to total ethnic populations to derive the split. Although Northern Ireland and England distributions may not be identical, the relatively small ethnic population in Northern Ireland (99.3 per cent of the population is White) means any discrepancy will have a minor impact on the economic cost estimates of partial sight and blindness. Table 2-2 shows the projected UK devolved nations populations by ethnicity for 2008. Most of the UK minority ethnic population reside in England (which is primarily concentrated in and around London) while Wales, Scotland and Northern Ireland have a relatively small proportion.

Projected UK country population by ethnicity, 2008. Figures in thousands.Table 2-2


England 45,888.6 1,383.2 2,724.7 804.2 687.3 51,488.0Scotland 5,055.7 7.9 54.8 12.6 25.9 5,157.1Wales 2,930.9 7.2 25.9 17.7 11.7 2,993.4N.I. 1,759.5 1.3 3.0 3.9 6.1 1,773.6UK 55,634.7 1,399.7 2,808.4 838.4 730.9 61,412.1

Figures as a percentageTable 2-2


England 89.1 2.7 5.3 1.6 1.3 100.0Scotland 98.0 0.2 1.1 0.2 0.5 100.0Wales 97.9 0.2 0.9 0.6 0.4 100.0N.I. 99.2 0.1 0.2 0.2 0.3 100.0Source: Access Economics calculations.

Age distribution of the minority ethnic population in the UK is shown in Figure 2-1. The distribution of a relatively younger population is expected given the waves of alternative ethnicities entering into the UK since the New Commonwealth immigration started in the 1950s. For example, the Black population has a relatively larger proportion of individuals that are above 60 years of age, reflecting the wave of this ethnic group into the UK in the 1950s and early 1960s. Also, the age structure of the Mixed ethnic group is skewed towards the young, which is a reflection of increased integration between white and minority ethnic populations.

Figure 2-1: Age distribution of projected minority ethnic population in the UK, 2008 in thousands

Age Black Asian Mixed Other0-4 110 240 150 355-9 95 210 115 3010-14 95 200 100 3015-19 105 230 95 5020-24 130 315 80 11025-29 125 320 60 11530-34 110 245 50 8035-39 145 220 50 6540-44 150 185 40 6045-49 105 170 30 5050-54 55 145 20 4055-59 30 85 10 2560-64 45 80 10 1565-69 40 70 8 1070-74 30 50 5 575-79 20 25 4 480-84 10 15 2 285-89 5 8 2 2

90+ 2 5 2 2


2.1.3 Long term UK population projectionsLong term UK population projections were also required in order to estimate the future prevalence of partial sight and blindness within the UK. Population projections of the UK population for 2010, 2020, 2030, 2040 and 2050 by age and five year age cohorts were derived from the Government Actuary’s Department (GAD, 2007) using the 2006-based principal projections. Unfortunately these projections do not include ethnic splits.

Over the long term there is expected to be a significant change in the ethnic composition of the UK population. For example, between 1981 and 2006 the proportion of foreign born people in the UK increased from just over 6 per cent to 10 per cent of the population, with the majority of this increase occurring since 2001 (House of Lords, 2008). In addition, GAD predicts that net migration between 2006 and 2031 will be around 4.9 million migrants, or around 69 per cent of the projected population growth (GAD, 2008). It is expected that the net migration will comprise British citizens dominating emigration and non-British citizens dominating immigration.

Methodological issues in developing ethnic population projections have been debated in the UK in recent years, starting with a comprehensive feasibility study by the ONS that consulted government departments and a wide range of academic specialists (ONS, 2002). Since then there have been a small number of local authorities that have estimated ethnic populations. For example, the Greater London Authority has developed a multi-borough projection model that uses hospital episode data to estimate fertility rates, Census data for inter-borough migration by ethnic group, and also incorporates housing capacity constraints. The ONS has estimated ethnic populations for areas within England between 2001 and 2005 based on a methodology developed by Large and Ghosh (2006a) but have not provided further ethnic projections.

There are two academic groups within the UK that have developed ethnic projections for the UK. Coleman (2006) from the Oxford Centre for Population Research has undertaken ethnic population projections for England and Wales across four ethnic groups, including White, Mixed, Asian and Black.

Assuming constant net immigration, Coleman predicted that minority ethnic populations would increase from around 4.5 million in 2001 (8.7 per cent) to about 15.5 million by 2051 (24.5 per cent).

The most comprehensive UK ethnic population projections, and the projections used in this study, have been undertaken by Rees and Parsons (2006) of the University of Leeds for the Joseph Rowntree Foundation (JRF). These projections were developed as an input to estimating child poverty in the UK out to 2020. Projections were made by England regions and UK countries to provide a total UK population projection for 2010 and 2020. This was done across five ethnic groups, including White, Black, Asian, Mixed and Other and across age cohorts, including 0-9, 10-15, 16-19, 20-24, 25-29, 30-44, 45-59, and 60+.

As the Rees and Parsons (2006) projections are not across five year age cohorts and only extended to 2020, assumptions were made to project the ethnic population to 2050. First, it was assumed that the growth rate in ethnic population across the broader age cohorts used within Rees and Parsons (2006) was applicable to each five year age cohort. For example, the growth rate for Asians for those 60+ between 2010 and 2020 derived from Rees and Parsons was 33 per cent, which was applied to all Asian five year age cohorts – 60-64, 65-69, 70-74 and so on – in the UK population projections between 2010 and 2020.

Applying growth rates from Rees and Parsons (2006) provided UK population projections up to 2020. However, using broad growth rates meant that the total population projection was different to the total population projected for 2020 by the GAD so each age cohort within each ethnic group was multiplied by an adjusting coefficient to ensure population projections were consistent. That is, Rees and Parsons (2006) projections were implicitly adjusted to ensure they were aligned with GAD projections of the total population.

In order to project the UK population out to 2030, 2040 and 2050, average ten year growth rates for ethnic populations between 2001 and 2020 were derived from Rees and Parsons (2006) and applied to the population projections for 2020. Once again, growth rates in broad age cohorts were applied to five year age cohorts and adjusting coefficients were applied to the total populations to ensure consistence with GAD total population projections. GAD population projections past 2031 are in five year brackets up to 2081. Consequently projections for 2041 were used for 2040 and projections for 2051 were used for 2050. It is not expected that there would be a significant difference between adjoining years given the uncertainty in population projections produced by GAD.

Table 2-3 outlines the projected UK country population by ethnicity between the years 2010 and 2050.

Projected UK country population by ethnicity, 2010-2050. Figures in thousands.Table 2-3


2010 56,455.6 1,415.1 2,848.8 847.7 742.2 62,309.52020 59,331.1 1,692.6 3,546.2 1,178.6 1,005.5 66,754.02030 61,049.4 2,172.8 4,361.8 1,661.9 1,504.5 70,750.42040 61,584.9 2,720.1 5,386.6 2,306.7 2,307.5 74,305.82050 60,749.8 3,485.8 6,442.2 3,187.7 3,370.2 77,235.8

Figures as a percentage.Table 2-3


2010 90.6 2.3 4.6 1.4 1.2 100.02020 88.9 2.5 5.3 1.8 1.5 100.02030 86.3 3.1 6.2 2.3 2.1 100.02040 82.9 3.7 7.2 3.1 3.1 100.02050 78.7 4.5 8.3 4.1 4.4 100.0Source: Access Economics calculations.

2.2 Prevalence rates by age, gender, ethnicity, severity and major regionA variety of data sources were utilised to estimate prevalence of partial sight and blindness by age, gender, ethnicity, region, severity and major cause. Ethnicity groupings were defined as per the population data, although ‘mixed’ and ‘other’ were combined into a single grouping ‘other’. Regions were also defined as per the population categories – the four UK countries and, within England, the nine English regions. Severity groupings were mild sight loss (<6/12-6/18), moderate sight loss (<6/18-6/60) and severe sight loss or blindness (<6/60). Major causes were categorised into the six groups of AMD, cataract, diabetic retinopathy, glaucoma, refractive error and other.

2.2.1 Partial sight and blindness in people aged 75 years and olderTotal partial sight and blindness data were derived from data from Evans et al (2002), who estimated the prevalence of partial sight and blindness in people aged 75 years and older in Britain using the MRC trial of assessment and management of older people in the community. In this trial, data were obtained from 14,600 participants aged 75 years and older. Partial sight and

blindness overall was defined as VA <6/18, low vision as VA <6/18 to 3/60, and blindness as VA <3/60. The prevalence of VA <6/12 was also presented for comparison with other studies.

Evans et al (2002) show rates of partial sight and blindness increasing from 10.8 per cent in those aged 75-79 years up to 53.1 per cent in those aged 90 years and older. Their results have been reproduced in Table 2-4.

Table 2-4: Prevalence of partial sight and blindness for the UK population 75 years and older (binocular visual acuity <6/18).All ages.Age Number Prevalence 95 per cent CITotal 14,600 19.9 17.8 to 22.0Men 5,620 15.2 13.5 to 16.9Women 8,980 22.8 20.3 to 25.3

Men and women.Age Number Prevalence 95 per cent CI75-79 6,898 10.8 9.1 to 12.680-84 4,602 20.0 17.6 to 22.485-89 2,319 35.3 31.7 to 38.890 plus 781 53.1 48.3 to 57.9

Men.Age Number Prevalence 95 per cent CI 75-79 2,961 8.9 7.1 to 10.7 80-84 1,695 16.3 14.3 to 18.4 85-89 782 30.2 25.9 to 34.5 90-94 182 42.3 34.5 to 50.1

Women.Age Number Prevalence 95 per cent CI 75-79 3,937 12.3 10.4 to 14.2 80-84 2,907 22.1 19.0 to 25.2 85-89 1,537 37.9 33.9 to 41.8 90-94 599 56.4 51.0 to 61.9Source: Evans et al (2002).

Disaggregation by cause and severityEvans et al (2004a) reported that, of the sub-group of 1,742 people with sight loss (<6/12) in the participating practices, 450 (26 per cent) achieved a pinhole VA in either eye of 6/18 or better. In these people, the principal

reason for visual loss was considered to be refractive error, and this is important for the modelling. The cause of visual loss was available for 976 (76 per cent) of the remaining 1,292 people with sight loss identified (<6/18). Apart from the ‘big five’ diseases, ‘other’ major causes of partial sight and blindness identified were vascular occlusions and myopic degeneration.

Causes of partial sight and blindness by age and gender as published in Evans et al (2004a) are shown in Table 2-5, Table 2-6, and Table 2-7. These shares were used, together with the overall prevalence of partial sight and blindness from Table 2-4, to estimate prevalence of partial sight and blindness by age, gender and major cause in those aged 75 years and older. The raw rates were adjusted downwards to account for comorbidities, because overall sight loss from the ‘big five’ and ‘other’ eye diseases cannot exceed 100 per cent but need to be ‘attributed’ (eg, 90+ women in Table 2-6 for the major five causes are 20 per cent+54 per cent+24 per cent+7 per cent+1 per cent>100 per cent). ‘Other’ represented 7.4 per cent after factoring down for comorbidities.

Table 2-5: Causes of partial sight and blindness (Binocular visual acuity <6/18).Cause No Binocular

partial sight and blindness(per cent)

Binocular partial sight and blindness (95 per cent CI)

Binocular partial sight and blindness, excluding refractive error (per cent)

Binocular partial sight and blindness, excluding refractive error (95 per cent CI)

Everyone aged 75 years and older (per cent)

Everyone aged 75 years and older (95 per cent CI)

Refractive error

450 31.6 28.3 to 34.8

- - 3.2 2.6 to 3.8

AMD 516 36.2 32.9 to 39.5

52.9 49.2 to 56.5

3.7 3.2 to 4.2

Cataract 350 24.5 21.8 to 27.4

35.9 31.7 to 40.1

2.5 2.0 to 3.0

Glaucoma 113 7.9 6.2 to 9.6 11.6 9.1 to 14.0

0.8 0.6 to 1.0

Diabetic eye disease

33 2.3 1.5 to 3.1 3.4 2.2 to 4.6 0.2 0.15 to 0.32

Vascular occlusions

9 0.6 0.1 to 1.1 0.9 0.2 to 1.6 0.06 0.01 to 0.11

Myopic degeneration

41 2.9 1.9 to 3.8 4.2 2.8 to 5.6 0.3 0.2 to 0.4

Other 67 4.7 3.7 to 5.7 6.9 5.5 to 8.2 0.5 0.4 to 0.6Note: Refractive error = people with pinhole corrected vision in right or left eye 6/18 or better; no cause was established in 316 people; total is more than 100 per cent as 16 per cent of people had more than one cause of visual loss. AMD = age related macular degeneration.Source: Evans et al (2004a).

Table 2-6: Causes of partial sight and blindness by age and sex (Binocular visual acuity <6/18).Men Number

in groupRefractive error (per cent)

AMD (per cent)

Cataract (per cent)

Glaucoma (per cent)

Diabetes (per cent)

75-79 113 40.7 23.0 17.7 9.7 8.080-84 141 32.6 33.3 19.2 12.1 5.085-89 120 33.3 37.5 28.3 10.8 0.890+ 36 22.2 55.6 33.3 2.8 0

Women No. in group

Refractive error (per cent)

AMD (per cent)

Cataract (per cent)

Glaucoma (per cent)

Diabetes (per cent)

75-79 234 42.3 20.5 24.4 4.7 1.780-84 309 34.0 36.3 22.3 7.8 1.685-89 311 23.8 42.1 29.6 7.7 1.990+ 162 19.8 53.7 24.1 7.4 0.6Source: Evans et al (2004a).

Table 2-7: Causes of partial sight and blindness (Binocular visual acuity <6/18).Low vision (<6/18-3/60)

Number in group


AMD (per cent)

Cataract (per cent)

Glaucoma (per cent)

Diabetes (per cent)

75-79 75-79 312 46.5 18.0 23.7 5.180-84 80-84 360 41.7 26.7 25.3 8.185-89 85-89 349 32.7 33.5 32.3 7.590+ 90+ 155 25.8 44.5 30.3 4.5

Blindness (<3/60)

No. in group


AMD (per cent)

Cataract (per cent)

Glaucoma (per cent)

Diabetes (per cent)

75-79 35 0 51.4 8.6 17.1 11.480-84 90 1.1 70.0 5.6 13.3 3.385-89 82 0 72.0 15.9 13.4 090+ 43 0 88.4 9.3 14.0 0Source: Evans et al (2004a).

After allocating these shares across the population for low vision and blindness, taking into account the factoring down for comorbidities and the allocation of the very mild cases to refractive error, the prevalence of partial sight and blindness by age, gender, cause and severity was estimated as summarised in Table 2-8.

Splits between mild, moderate and severe sight loss in Table 2-8 were based on Evans et al (2004a), using the relativities between the <6/18, 6/18-3/60 and <3/60 groups, together with a parameter estimating the proportion of blindness <6/60 relative to all partial sight and blindness (<6/12). This enabled a separation of those with VA<6/60 from those with VA<3/60 and a separation of VA<6/12-6/18. Overall, this parameter was based on two sources. Reidy et al (1998) presents results from the North London Eye Study

(NLES), which was carried out from April 1995 to October 1996 and included 1,547 people aged 65 years and older of whom 1,459 (94.3 per cent) were white. This study separated partial sight and blindness severity into the three groupings of interest in this report: <6/12-6/18, <6/18-6/60 and worse than 6/60. Population prevalence of bilateral partial sight and blindness (<6/12) was around 30 per cent and 92 of these 448 cases (21 per cent) had VA <6/60 in one or both eyes. This 21 per cent parameter was considered as one bound (the upper bound for the 75+ population of interest) on the proportion of people with VA<6/60 of those with VA<6/12. The Reidy et al (1998) data were at the higher end of the data reviewed. For example, Reidy et al (1998) found 30 per cent partial sight and blindness from cataract, while Wormald et al (1992) found 1 per cent in the 65-74 group and 10.4 per cent in the 75+ group.

Evans et al (2002) showed blindness measured as <3/60 as 2.1 per cent and partial sight and blindness (<6/12) as 19.9 per cent across the 75+ population. The ratio of these rates was necessarily a lower bound (10.6 per cent).

The average of the two estimates (15.8 per cent) was used as the parameter for blindness as a share of total sight loss in the 75+ age group.

Table 2-8: Partial sight and blindness prevalence (per cent) by age, gender, cause and severity (75+).

AMD malesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

75-79 1.4 0.4 0.3 0.780-84 3.6 1.2 0.7 1.885-89 7.0 2.4 1.5 3.190 and over 14.1 6.8 2.5 4.9

AMD femalesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

75-79 1.7 0.3 0.4 1.080-84 5.4 2.0 0.9 2.485-89 10.4 4.7 1.8 3.990 and over 19.7 9.8 3.3 6.5

Cataract malesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

75-79 1.1 0.8 0.2 0.180-84 2.1 1.5 0.5 0.185-89 5.3 3.6 1.1 0.690 and over 8.5 6.3 1.6 0.5

Cataract femalesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

75-79 2.1 1.2 0.6 0.280-84 3.3 2.1 1.0 0.285-89 7.3 4.4 1.9 1.090 and over 8.8 5.9 2.3 0.7

Diabetic disease malesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

75-79 0.49 0.11 0.11 0.2680-84 0.55 0.20 0.20 0.1685-89 0.15 0.07 0.07 0.0090 and over 0.03 0.01 0.01 0.00

Diabetic disease femalesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

75-79 0.14 0.02 0.02 0.1180-84 0.24 0.07 0.07 0.0985-89 0.47 0.23 0.23 0.0190 and over 0.22 0.11 0.11 0.00

Glaucoma malesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

75-79 0.6 0.3 0.1 0.280-84 1.3 0.7 0.2 0.485-89 2.0 1.1 0.3 0.690 and over 0.7 0.4 0.1 0.3

Glaucoma femalesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

75-79 0.4 0.1 0.1 0.280-84 1.2 0.6 0.2 0.385-89 1.9 1.0 0.3 0.690 and over 2.7 1.4 0.3 1.0

Refractive error malesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

75-79 4.7 3.5 1.2 0.080-84 7.5 5.6 1.8 0.085-89 13.5 10.1 3.3 0.090 and over 15.8 11.9 3.9 0.0

Refractive error femalesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

75-79 7.1 5.3 1.7 0.080-84 10.4 7.8 2.6 0.085-89 15.0 11.3 3.7 0.090 and over 20.8 15.6 5.1 0.1

“Other” malesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

75-79 0.66 0.30 0.30 0.0580-84 1.21 0.54 0.54 0.1385-89 2.24 0.90 0.90 0.4490 and over 3.13 1.08 1.08 0.97

“Other” femalesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

75-79 0.91 0.29 0.29 0.3280-84 1.64 0.62 0.62 0.3985-89 2.81 1.16 1.16 0.4890 and over 4.18 1.77 1.77 0.63

Total malesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

75-79 8.9 5.36 2.13 1.4080-84 16.3 9.76 3.97 2.5785-89 30.2 18.23 7.21 4.7690 and over 42.3 26.44 9.18 6.67

Total femalesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

75-79 12.3 7.27 3.09 1.9480-84 22.1 13.21 5.40 3.4985-89 37.9 22.74 9.18 5.9890 and over 56.4 34.62 12.88 8.90Source: Access Economics calculations based on Evans et al (2002, 2004a).

The following sources were also used to refine the splits by severity and type of disease, in particular to smooth prevalence relativities by age. AMD - Evans et al (2002b) Cataracts – Data supplied by A. Reidy (pers. comm) from the NLES Glaucoma - Owen et al (2006) and Coffey et al (1993):1 1 Owen et al (2006) was based on computerised data (the DIN-LINK

database) from 131 general practices across the UK, in which half a million patients aged 40 years or more were registered annually, were used. On

average 10,000 patients were treated for glaucoma and ocular hypertension annually.

2 Coffey et al (1993) looked at the prevalence of glaucoma in the west of Ireland.

2.2.2 Partial sight and blindness in people aged under 75 yearsA large number of sources were used to estimate partial sight and blindness by age, gender, cause and severity in those aged under 75 years.

65-74 years – total partial sight and blindnessVan der Pols et al (2000) carried out VA measurements in the context of the national diet and nutrition survey (NDNS) of people aged 65 years or over (fieldwork was carried out in 1994-95). VA was measured in 1,362 NDNS participants who were not classified as mentally impaired. Sight loss was measured in 195 (14.3 per cent) subjects with ‘low vision’ defined by the WHO criteria as VA <6/18 in the better eye and ‘partial sight’ defined according to US criteria is VA <6/12 and better than 6/60. For VA<6/18, prevalence was 1.8 per cent in males 65-74 and 4.7 per cent in females of this age – 2.5 per cent for all 65-74 year old people. For VA<6/12, prevalence was 9.8 per cent in the 65-74 age group. These data were used to estimate the overall prevalence of partial sight and blindness and of mild sight loss in the 65-69 and 70-74 age groups, adjusting downwards for the relative difference between van der Pols et al (2000) and Evans et al (2002) in the 75+ groups – since van der Pols found much higher prevalence in that group (60 per cent in 85+ and 26 per cent in 75-84 for VA<6/12 compared to the Evans et al (2002) finding of 26 per cent in 85+ and 15 per cent in 75-84).

Under 65 – total partial sight and blindnessTotal partial sight and blindness prevalence rates in the 40-65 age groups were derived from English and Scottish data from Charles et al (2007), together with relativities by age and gender from the Eye Disease Prevalence Research Group (EDPRG) international multi-site data (Congdon et al, 2004) applied to the older age groups as derived from UK sources (Section 2.2.1). For example, Congdon et al (2004) showed a relativity of 0.88/1.47 or 60 per cent between sight loss in the 60-64 group compared to the 65-69 group. With sight loss of 5.2 per cent and 5.9 per cent estimated in 65-69 year old males and females respectively in the UK, this ratio implies sight loss of 3.1 per cent and 3.5 per cent respectively in the 60-64 year old males and females.

Charles et al (2007) was particularly useful for the groups aged under 40 years (where there are no EDPRG data) and for severity splits (using

weighted averages of the English and Scottish rates). Charles et al (2007) based their estimates on the two UK national prevalence studies by Evans et al (2002) and van der Pols et al (2000), as these were identified as ‘most reliable’ in a literature review carried out under the supervision of Professor Astrid Fletcher. The MRC and NDNS studies were also identified as reporting the most reliable prevalence estimates by a review of the epidemiological evidence commissioned by RNIB (Tate et al, 2005). Tables 3 and 4 in Charles et al (2007) summarise the counts (or estimates of them) by local authority social service and social work departments of those who are registered as sight impaired and severely sight impaired in England and Scotland.

Under 40s and severity-type splitsTotal partial sight and blindness was also estimated in those aged under 40 as well as the distribution of partial sight and blindness in the under 65 group by type of eye disease with severity splits. As with the 75+ group, a number of different sources were used in this estimation process. Relativities from the overall rates of partial sight and blindness (derived

from the Evans et al (2002)-adjusted van der Pols (2000) data as described above) were one input.

Owen et al (2003) and data supplied by A. Reidy (pers. comm) from the NLES were used for AMD and cataract, and Desai et al (1999) was also used for cataract.

Owen et al (2006) and Coffey et al (1993) were used for glaucoma. Data from the EDPRG and from previous detailed Access Economics

modelling including: 1 for AMD, Access Economics (2006) and Friedman et al (2004);2 for cataract, Access Economics (2004, forthcoming) and Congdon et al

(2004a);3 for diabetic diseases, Access Economics (forthcoming) and Kempen et al

(2004);4 for glaucoma, Access Economics (2007) and Friedman et al (2004a); and5 for refractive error, Access Economics (2004, forthcoming) and Kempen

(2004a).

A summary of the prevalence rates derived for the younger age groups is provided in Table 2-9 (55-74 years) and Table 2-10 (under 55, excluding cells where the prevalence rate is zero and also excluding ‘other’, noting it can be derived as a residual from the table).

Table 2-9: Partial sight and blindness prevalence (per cent) by age, gender, cause and severity (55-74).

AMD malesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

55-59 0.10 0.10 - -60-64 0.10 0.10 - -65-69 0.28 0.24 0.04 0.0170-74 1.09 1.00 0.06 0.03

AMD femalesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

55-59 0.10 0.10 - -60-64 0.10 0.10 - -65-69 0.62 0.51 0.09 0.0270-74 0.65 0.41 0.15 0.09

Cataract malesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

55-59 0.19 0.11 0.04 0.0460-64 0.31 0.18 0.06 0.0665-69 0.53 0.32 0.11 0.1070-74 0.72 0.43 0.15 0.13

Cataract femalesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

55-59 0.26 0.15 0.07 0.0460-64 0.45 0.26 0.13 0.0665-69 0.84 0.49 0.23 0.1270-74 1.33 0.43 0.71 0.19


<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

55-59 0.24 0.08 0.08 0.0860-64 0.24 0.08 0.08 0.0865-69 0.40 0.13 0.13 0.1470-74 0.40 0.13 0.13 0.14


<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

55-59 0.16 0.06 0.06 0.0360-64 0.16 0.06 0.06 0.0365-69 0.23 0.09 0.09 0.0470-74 0.23 0.09 0.09 0.04

Glaucoma malesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

55-59 0.10 0.04 0.02 0.0360-64 0.19 0.01 0.07 0.1165-69 0.35 0.02 0.17 0.1670-74 0.51 0.03 0.25 0.22

Glaucoma femalesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

55-59 0.10 0.04 0.02 0.0360-64 0.17 0.01 0.06 0.1065-69 0.31 0.02 0.15 0.1470-74 0.37 0.02 0.18 0.16


<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

55-59 1.22 0.91 0.30 0.0160-64 2.07 1.55 0.50 0.0165-69 3.28 2.46 0.80 0.0270-74 4.23 3.17 1.03 0.03


<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

55-59 1.46 1.09 0.36 0.0160-64 2.39 1.79 0.58 0.0265-69 3.46 2.59 0.84 0.0270-74 4.50 3.37 1.10 0.03

“Other” malesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

55-59 0.15 0.10 0.03 0.0160-64 0.23 0.16 0.05 0.0265-69 0.39 0.27 0.08 0.0470-74 0.56 0.39 0.11 0.06

“Other” femalesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

55-59 0.17 0.12 0.03 0.0260-64 0.26 0.18 0.05 0.0365-69 0.44 0.31 0.09 0.0470-74 0.57 0.40 0.11 0.06

Total malesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

55-59 1.99 1.35 0.47 0.1860-64 3.13 2.08 0.76 0.2965-69 5.23 3.45 1.32 0.4670-74 7.49 5.15 1.73 0.61

Total femalesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

55-59 2.24 1.57 0.54 0.1360-64 3.52 2.40 0.88 0.2465-69 5.89 4.00 1.50 0.3970-74 7.64 4.73 2.34 0.57Source: Access Economics modelling for various sources.

Table 2-10: Partial sight and blindness prevalence (per cent) by age, gender, cause and severity (<55).

Cataracts malesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

40-49 0.05 0.05 - -50-54 0.11 0.07 0.02 0.02

Cataracts femalesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

40-49 0.05 0.05 - -50-54 0.15 0.08 0.04 0.02


<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

30-34 0.02 0.01 0.01 0.0135-39 0.06 0.02 0.02 0.0240-44 0.09 0.03 0.03 0.0345-49 0.09 0.03 0.03 0.0350-54 0.24 0.08 0.08 0.08


<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

25-29 0.01 0.00 0.00 0.0030-34 0.02 0.01 0.01 0.0035-39 0.04 0.01 0.01 0.0140-44 0.05 0.02 0.02 0.0145-49 0.05 0.02 0.02 0.0150-54 0.16 0.06 0.06 0.03

Glaucoma malesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

40-44 0.10 0.04 0.02 0.0345-49 0.10 0.04 0.02 0.0350-54 0.10 0.04 0.02 0.03

Glaucoma femalesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

45-49 0.08 0.04 0.01 0.0350-54 0.08 0.04 0.01 0.03


<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

0-4 0.09 0.06 0.02 0.0015-9 0.13 0.10 0.03 0.00110-14 0.17 0.13 0.04 0.00115-19 0.22 0.16 0.05 0.00120-24 0.24 0.18 0.06 0.00225-29 0.27 0.20 0.07 0.00230-34 0.25 0.19 0.06 0.00235-39 0.22 0.17 0.05 0.00140-44 0.55 0.42 0.13 0.00445-49 0.78 0.59 0.19 0.00550-54 0.87 0.65 0.21 0.006


<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

0-4 0.08 0.06 0.02 0.0005-9 0.12 0.09 0.03 0.00110-14 0.15 A 0.12 0.04 0.00115-19 0.20 0.15 0.05 0.00120-24 0.22 0.16 0.05 0.00125-29 0.24 0.18 0.06 0.00230-34 0.23 0.17 0.06 0.00135-39 0.22 0.16 0.05 0.00140-44 0.71 0.53 0.17 0.00545-49 0.97 0.73 0.24 0.00650-54 1.08 0.81 0.26 0.007

Total malesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

0-4 0.09 0.07 0.02 0.0015-9 0.14 0.10 0.03 0.00210-14 0.18 0.14 0.04 0.00215-19 0.24 0.18 0.06 0.00320-24 0.26 0.20 0.06 0.00425-29 0.29 0.22 0.07 0.00530-34 0.30 0.21 0.07 0.0135-39 0.30 0.20 0.08 0.0240-44 0.86 0.58 0.20 0.0745-49 1.10 0.77 0.26 0.0850-54 1.42 0.91 0.36 0.15

Total femalesAge

<6/12 <6/12-6/18 <6/18-6/60 <6/60 (blind)

0-4 0.08 0.06 0.02 0.0015-9 0.13 0.09 0.03 0.00210-14 0.17 0.12 0.04 0.00215-19 0.21 0.16 0.05 0.00320-24 0.24 0.18 0.06 0.00425-29 0.27 0.20 0.06 0.00530-34 0.27 0.19 0.07 0.0135-39 0.27 0.19 0.07 0.0140-44 0.96 0.69 0.22 0.0545-49 B 1.24 0.90 0.29 0.0550-54 1.60 1.09 0.41 0.10Source: Source: Access Economics modelling for various sources.

2.2.3 Ethnicity and regional splitsEthnicity splitsEthnicity splits were then applied to the overall prevalence rates – by age, gender and severity – based on relative risks for particular eye diseases (also by age, gender and severity), from the literature.

Johnson and Scase (2000) concluded that there is no agreed, comprehensive and reliable source of information on the prevalence of partial sight and blindness among minority ethnic groups in the UK. The majority of studies of minority ethnic groups and their health in Britain have not collected data about partial sight and blindness. The exception is a study by Bhalla and

Blakemore (1981) which showed high reported rates of sight problems (61 per cent for African-Caribbean and 53 per cent Asian contrasted with 52 per cent for an older white control population).

Apart from the EDPRG data, one key UK source for ethnicity data was Das et al (1994, 1990), who examined 377 people and found that Asians had a significantly higher prevalence of cataract compared to people of European descent (30 per cent compared to 3 per cent in people aged under 60 years and 78 per cent compared to 54 per cent in those aged 60 years and over). The markedly higher prevalence of cataract in Asians under 60 suggests an earlier onset of the disease in Asian people. After adjusting for age, the prevalence did not differ significantly with gender. The higher prevalence of cataract in Asians has also been found in other population-based studies from India and in a hospital-based study in Leicester (Thompson, 1989). Thompson (1989) was based on demand incidence and does not wholly support the widespread belief that there is under-utilisation (or avoidance) among the Asian community. However if this does exist, he may be underestimating the true levels of need. Das et al (1994, 1990) obtained a higher response rate from Asian than White (‘Caucasian’) samples and reports substantially higher prevalence (24 per cent compared to 0 per cent in those aged 40 to 59, and 73 per cent compared to 41 per cent for ages over 60).

Research has also investigated the epidemiology of glaucoma among African-Caribbean people living in London (Wormald et al, 1994), a group with significantly higher rates of this disease. The purpose of the study was to estimate the prevalence of, and risk factors for, chronic glaucoma in a sample of African Caribbean people over 35 years of age living in the London Borough of Haringey. Of 873 eligible persons examined (out of a total of 1022), 32 definite cases of glaucoma were identified, a prevalence of 3.9 per cent and 42 per cent of these had been previously diagnosed. An age-standardised comparison with the findings of the Roscommon survey revealed a relative risk for glaucoma for the Haringey black population compared with Irish whites of 3.7. Despite the lack of a population base, this study provides strong evidence that the four times greater risk of glaucoma estimated for American blacks compared with whites applies equally to the United Kingdom population.

Table 2-11 shows the relative risk of selected eye diseases due to ethnicity. In summary: The black population has a greater risk of developing AMD compared to

the white population in younger age groups, whereas the white population

has a greater risk of developing AMD in the latter years of life; Asians are at lower risk than whites of AMD (Friedman et al 2004; Das et al 1994).

Asians have a greater risk of developing cataracts compared to the black population and white population (Kempen et al 2004; Das et al 1994).

Black and Asian populations have a greater risk of developing diabetic eye disease compared to the white population (Kempen et al 2004; Das et al 1994).

The relative risk of glaucoma is much higher for the black population compared to the white population (Friedman et al 2004a; Wormald et al 1994).

The white population has the greater risk in developing refractive error compared to the black population (Kempen et al 2004a).

For other eye disease, no robust differences in relative risk as a result of ethnicity have been found (Munier et al 1998; Ghafour et al 1983).

Tables 2-11: Relative risk of selected eye diseases due to ethnicity (black to white ratio). Black, white and 'Asian' populations.AMD Males (black:white) Females (black:white)50-54 1.235 3.40055-59 1.268 3.72760-64 1.000 2.85765-69 0.713 1.72970-74 0.470 0.96775-79 0.287 0.52080+ 0.131 0.14970+ males (Asian: white): 0.43870+ females (Asian: white): 0.821

Cataract Males (black:white)

Females (black:white)

Populations(Asian:white)

40-49 0.607 1.158 11.00050-54 0.918 1.460 8.16755-59 0.927 1.362 8.16760-64 0.862 1.189 2.30065-69 0.781 1.029 2.30070-74 0.711 0.912 1.45375-79 0.663 0.843 1.45380+ 0.648 0.795 1.453

Diabetic disease Males (black:white) Females (black:white)40-49 1.450 1.91750-64 1.222 2.12465-74 0.621 1.41775+ 1.110 1.209All ages (Asian: white): 1.353

Glaucoma Males (black:white) Females (black:white)40-49 1.528 1.81950-54 2.803 2.51755-59 3.600 2.80460-64 4.186 2.96765-69 4.415 2.93770-74 4.238 2.72775-79 3.710 2.38880+ 2.367 1.415

Refractive error Males (black:white) Females (black:white)40-49 0.614 0.43050-54 0.604 0.49355-59 0.551 0.53960-64 0.468 0.57265-69 0.373 0.59170-74 0.281 0.60075-79 0.202 0.60480+ 0.096 0.616

Total prevalence rates by ethnicity were calculated ‘bottom up’ as the sum of prevalence from the relative risks, and fitted back proportionally into the total population of people with partial sight and blindness as estimated in Section 2.2.2.

Regional splits and literature summaryAfter allowing for age, gender and ethnicity, there were no sources investigated in the literature that showed further differences in the prevalence or severity of partial sight and blindness attributable to region within the UK. As such, the prevalence modelling by region was based on the demographic differences alone. A summary of prevalence sources used in the modelling is provided in Table 2-12.

Table 2-12: Summary of Prevalence sourcesAge group

Total VI by age/gender

Severity splits Type of eye disease

75+ Evans et al (2002)

Evans et al (2004a) for mild sight loss

Evans et al (2004a) for shares of ‘big 5’ and ‘other’ in total


Blind: 15.8 per cent parameter for VA<6/60 relative to VA<6/12 from Evans et al (2004a) lower bound and Reidy et al (1998) upper bound

AMD: Evans et al (2004b)


Moderate derived as a residual

Cataract: NLES data from Reidy


Moderate derived as a residual

Glaucoma: Owen et al (2006); Coffey et al (1993)

65-74 Van der Pols (2000)

- Relativities from older age groups and Van der Pols (2000), Owen et al (2003, 2006); Reidy NLES data, Desai et al (1999), Coffey et al (1993), Access Economics (2004, 2006, 2007, forthcoming), Congdon et al (2004, 2004a), Friedman et al (2004, 2004a), Kempen et al (2004, 2004a).

40-64 Congdon et al (2004) relativities

- Relativities from older age groups and Van der Pols (2000), Owen et al (2003, 2006); Reidy NLES data, Desai et al (1999), Coffey et al (1993), Access Economics (2004, 2006, 2007, forthcoming), Congdon et al (2004, 2004a), Friedman et al (2004, 2004a), Kempen et al (2004, 2004a).

Age group

Total VI by age/gender

Severity splits Type of eye disease

Under 40s

- - Relativities from older age groups and Van der Pols (2000), Owen et al (2003, 2006); Reidy NLES data, Desai et al (1999), Coffey et al (1993), Access Economics (2004, 2006, 2007, forthcoming), Congdon et al (2004, 2004a), Friedman et al (2004, 2004a), Kempen et al (2004, 2004a).

Ethnicity splits

- Congdon et al (2004, 2004a), Friedman et al (2004, 2004a), Kempen et al (2004, 2004a), Das et al (1994), Wormald et al (1994).

Congdon et al (2004, 2004a), Friedman et al (2004, 2004a), Kempen et al (2004, 2004a), Das et al (1994), Wormald et al (1994).

Other literature sources reviewed but not used directly in the prevalence modelling are provided in the following section (note some of these were reviewed by the EDPRG and form part of their estimates). Tables of prevalence rates for males and females, by age and severity, are presented in Figure 2-3.

2.3 Prevalence of partial sight and blindness in the UKApplying the prevalence rates estimated in Sections 2.2 to the UK population data estimated in Section 2.1 provided estimates of the numbers of people with partial sight and blindness in the UK for the base year 2008. Table 2-13 shows a total of 1.8 million people with partial sight and blindness in 2008. In summary, it was estimated that approximately: 1.13 million (63 per cent) were female and 664,000 (37 per cent) were

male; 300,000 (16.7 per cent) had partial sight and blindness due to AMD; 246,000 (13.7 per cent) had partial sight and blindness due to cataract; 95,000 (5.3 per cent) had partial sight and blindness due to glaucoma;

62,000 (3.5 per cent) had partial sight and blindness due to diabetic retinopathy;

960,000 (53.5 per cent) had partial sight and blindness due to refractive error; and

133,000 (7.4 per cent) had partial sight and blindness due to other eye diseases.

Table 2-14 shows there was an estimated total of 218,000 blind people in the UK in 2008. In summary, it was estimated that approximately: 140,000 (64.3 per cent) were female and 78,000 (35.7 per cent) were

male; 110,000 (50.5 per cent) were blind due to AMD; 27,000 (12.5 per cent) were blind due to cataract; 36,000 (16.6 per cent) were blind due to glaucoma; 19,000 (8.7 per cent) were blind due to diabetic retinopathy; 5,000 (2.1 per cent) were blind due to refractive error; and 21,000 (9.7 per cent) were blind due to other eye diseases.

Table 2-13: Partial sight and blindness (<6/12) by age, gender and disease type, UK (people) 2008Male AMD Cataract DR Glaucoma RE Other Total 0- 39 - - 1,674 - 32,203 2,710 36,587 40-44 - 1,194 2,146 2,241 12,957 1,483 20,020 45-49 - 1,093 1,965 2,052 16,794 1,752 23,657 50-54 - 2,111 4,504 1,874 16,330 1,986 26,804 55-59 1,792 3,377 4,286 1,783 21,827 2,645 35,710 60-64 1,777 5,440 4,251 3,308 36,755 4,122 55,654 65-69 3,762 7,056 5,291 4,630 43,643 5,151 69,534 70-74 12,232 8,072 4,475 5,685 47,521 6,239 84,223 75-79 12,226 9,409 4,253 5,156 40,790 5,747 77,580 80-84 21,115 12,175 3,170 7,673 43,441 7,006 94,580 85-89 21,946 16,562 468 6,321 42,251 7,004 94,552 90+ 15,090 9,038 27 760 16,896 3,345 45,157Total males 89,941 75,527 36,511 41,482 371,408 49,190 664,059

Female AMD Cataract DR Glaucoma RE Other Total 0- 39 - - 1,318 - 28,645 2,397 32,360 40-44 - 1,164 1,296 1,829 16,881 1,694 22,864 45-49 - 1,079 1,202 1,696 21,354 2,026 27,358 50-54 - 2,805 3,030 1,841 20,880 2,284 30,840 55-59 1,846 4,886 2,905 1,765 26,931 3,067 41,399 60-64 1,860 8,291 2,928 3,186 44,436 4,856 65,557 65-69 8,933 11,977 3,223 4,390 49,474 6,240 84,236 70-74 8,329 17,017 2,878 4,755 57,467 7,236 97,682 75-79 19,216 22,872 1,594 4,406 78,585 10,134 136,806 80-84 47,224 29,011 2,081 10,147 90,855 14,345 193,664 85-89 62,688 44,075 2,829 11,465 90,424 16,918 228,399 90+ 59,848 26,859 669 8,247 63,418 12,723 171,765Females 209,945 170,035 25,952 53,727 589,350 83,921 1,132,931

Total AMD Cataract DR Glaucoma RE Other Totalmales and female 299,886 245,562 62,463 95,209 960,758 133,110 1,796,990Source: Access Economics modelling.

Table 2-14: Blindness (<6/60) by age, gender and disease type, UK (people) 2008

Male AMD Cataract DR Glaucoma RE Other Total0- 39 - - 583 - 205 271 1,05940-44 - - 748 773 82 148 1,75245-49 - - 685 708 107 175 1,67550-54 - 396 1,570 647 104 199 2,91555-59 - 634 1,494 615 139 265 3,14660-64 - 1,021 1,481 1,999 234 412 5,14765-69 108 1,324 1,844 2,076 278 515 6,14470-74 365 1,514 1,559 2,501 302 624 6,86675-79 6,486 720 2,292 2,158 108 476 12,23980-84 10,372 616 907 2,130 132 764 14,92185-89 9,773 1,724 6 1,890 139 1,385 14,91790 and over 5,235 534 0 270 53 1,032 7,124Total (male) 32,338 8,482 13,169 15,767 1,883 6,266 77,906

Female AMD Cataract DR Glaucoma RE Other Total0- 39 - - 259 - 182 240 68140-44 - - 255 653 107 169 1,18445-49 - - 236 605 136 203 1,18050-54 - 401 596 657 133 228 2,01555-59 - 698 571 630 171 307 2,37760-64 - 1,185 576 1,925 283 486 4,45465-69 313 1,712 634 1,968 315 624 5,56670-74 1,119 2,432 566 2,092 366 724 7,29875-79 11,437 2,418 1,187 2,753 208 3,580 21,58380-84 21,239 1,989 807 2,817 277 3,424 30,55385-89 23,607 5,758 43 3,429 298 2,899 36,03390 and over 19,913 2,117 14 2,925 198 1,932 27,098Total (female) 77,627 18,710 5,744 20,453 2,674 14,815 140,024

Male and female AMD Cataract DR Glaucoma RE Other TotalTotal 109,965 27,193 18,913 36,221 4,557 21,082 217,930Source: Access Economics modelling.

The severity of partial sight and blindness is presented in Table 2-15, which shows: 63.4 per cent had mild sight loss (largely due to refractive error), with the

proportion falling with age; 24.5 per cent had moderate sight loss; and 12.1 per cent were considered blind (severe sight loss), with the proportion

who are blind rising with age.

Table 2-15: Partial sight and blindness by age, gender and severity, UK (people) 2008.Note: Mild <6/12-6/18; Moderate <6/18-6/60; Severe (blind) <6/60.

Male MildModerate(number)

Severe(number)

Mild(number)

Moderate(per cent)

Severe(per cent)

0- 39 26,595 8,933 1,059 72.7 24.4 2.940-44 13,643 4,625 1,752 68.1 23.1 8.845-49 16,467 5,516 1,675 69.6 23.3 7.150-54 17,206 6,684 2,915 64.2 24.9 10.955-59 24,232 8,332 3,146 67.9 23.3 8.860-64 37,024 13,483 5,147 66.5 24.2 9.265-69 45,813 17,577 6,144 65.9 25.3 8.870-74 57,929 19,428 6,866 68.8 23.1 8.275-79 46,737 18,604 12,239 60.2 24.0 15.880-84 56,643 23,016 14,921 59.9 24.3 15.885-89 57,063 22,572 14,917 60.4 23.9 15.890 and over 28,229 9,804 7,124 62.5 21.7 15.8Total (male) 427,581 158,572 77,906 64.4 23.9 11.7

Female MildModerate(number)

Severe(number)

Mild(number)

Moderate(per cent)

Severe(per cent)

0- 39 23,691 7,988 681 73.2 24.7 2.140-44 16,371 5,308 1,184 71.6 23.2 5.245-49 19,775 6,402 1,180 72.3 23.4 4.350-54 20,938 7,887 2,015 67.9 25.6 6.555-59 28,984 10,038 2,377 70.0 24.2 5.760-64 44,673 16,430 4,454 68.1 25.1 6.865-69 57,276 21,394 5,566 68.0 25.4 6.670-74 60,435 29,949 7,298 61.9 30.7 7.575-79 80,814 34,409 21,583 59.1 25.2 15.880-84 115,772 47,339 30,553 59.8 24.4 15.885-89 137,055 55,311 36,033 60.0 24.2 15.890 and over 105,426 39,240 27,098 61.4 22.8 15.8Total (female) 711,211 281,696 140,024 62.8 24.9 12.4

Total MildModerate(number)

Severe(number)

Mild(number)

Moderate(per cent)

Severe(per cent)

male and female 1,138,792 440,268 217,930 63.4 24.5 12.1Source: Access Economics modelling. Note: Mild <6/12-6/18; Moderate <6/18-6/60; Severe (blind) <6/60.

Table 2-16 presents the ethnicity splits. Of the estimated 1.8 million with partial sight and blindness in the UK, approximately: 1.73 million (96.4 per cent) were white – a population prevalence of 3.1

per cent; 13,200 (0.7 per cent) were black – a population prevalence of 0.9 per cent; 38,000 (2.1 per cent) were Asian – a population prevalence of 2.1 per

cent; and 13,000 (0.7 per cent) were other ethnicities – a population prevalence of

0.9 per cent.

Table 2-16: Partial sight and blindness (<6/12) by age, gender and ethnicity, UK (people) 2008

Males White Black Asian Other Total0- 39 31,784 1,078 2,367 1,359 36,58740-44 17,708 502 1,371 439 20,02045-49 21,267 427 1,540 423 23,65750-54 24,436 321 1,700 347 26,80455-59 33,763 244 1,384 319 35,71060-64 53,311 459 1,478 406 55,65465-69 66,040 753 2,244 497 69,53470-74 80,990 726 1,998 508 84,22375-79 75,516 443 1,274 347 77,58080-84 92,912 292 1,034 342 94,58085-89 92,945 253 1,024 330 94,55290 and over 44,537 63 368 190 45,157All males 635,208 5,561 17,783 5,507 664,059Male (per cent of population) 2.3 per cent 0.8 per cent 1.2 per cent 0.7 per cent 2.2 per cent

Female White Black Asian Other Total0- 39 28,126 994 2,025 1,215 32,36040-44 20,451 540 1,327 546 22,86445-49 24,733 456 1,593 576 27,35850-54 28,043 419 1,886 492 30,84055-59 38,684 428 1,816 471 41,39960-64 62,502 783 1,718 554 65,55765-69 80,494 1,121 2,044 576 84,23670-74 94,399 903 1,847 533 97,68275-79 133,775 757 1,679 595 136,80680-84 190,940 529 1,551 644 193,66485-89 225,443 447 1,742 767 228,39990 and over 170,137 220 889 519 171,765All females 1,097,728 7,598 20,118 7,487 1,132,931Female (per cent of population) 3.9 per cent 1.1 per cent 1.5 per cent 0.9 per cent 3.6 per cent

Total White Black Asian Other TotalMale and female 1,732,937 13,158 37,901 12,993 1,796,990Total (per cent of population) 3.1 per cent 0.9 per cent 1.3 per cent 0.8 per cent 2.9 per centSource: Access Economics modelling.

2.4 Projections of prevalence to 2050Applying the prevalence rates estimated in Sections 2.2 to the UK population projections from Section 2.1 provides estimates of the numbers of people with partial sight and blindness in the UK for the years 2008 to 2050. The main findings are summarised in Table 2-17 showing more than a doubling (115 per cent increase over 2010) in the numbers of people with partial sight and blindness in the UK, to nearly 4 million people by 2050. Of these: 1.6 million (40 per cent) will be males and 2.4 million (60 per cent) will be

females; population prevalence will rise from 3.0 per cent in 2010 (2.3 per cent for

males and 3.7 per cent for females) to 5.2 per cent (4.1 per cent for males and 6.2 per cent for females) in 2050;

the proportion of whites with partial sight and blindness will fall (to 94.1 per cent), while the proportion of blacks will increase to 0.9 per cent, Asians to 3.2 per cent, and others to 2 per cent.

Figure 2-4 highlights the projected increase in prevalence rates and numbers, while Table 2-18 summarises the changes in shares contributed by different eye diseases. From 2010 to 2050, the share of partial sight and blindness from: AMD increases from 16.8 per cent to 22.2 per cent (nearly doubling to

890,000 people), reflecting demographic ageing; cataract increases from 13.7 per cent to 15.2 per cent (increasing 140 per

cent to 600,000 people), likewise; diabetic retinopathy decreases from 3.4 per cent to 2.3 per cent (a 46 per

cent increase in absolute numbers though, to 93,000 people); glaucoma decreases slightly from 5.3 per cent to 5.0 per cent (but doubles

in absolute terms to over 200,000 people); refractive error decreases from 53.3 per cent to 47.8 per cent (but also

nearly doubles, to 1.9 million people); and other eye disease stays constant (rising in absolute terms to nearly

300,000 cases).

Table 2-17: Projection of partial sight and blindness (<6/12) by gender and ethnicity, UK (people)

Table 2-17

2010 2020 2030 2040 2050 per cent increase 2050/2010

Males 695,867 893,719 1,147,663 1,389,000 1,585,304 128 per cent

per cent pop'n

2.3 per cent

2.7 per cent

3.3 per cent

3.8 per cent

4.1 per cent

-

Females 1,161,195 1,368,405 1,727,730 2,111,485 2,407,213 107 per cent

per cent pop'n

3.7 per cent

4.1 per cent

4.8 per cent

5.6 per cent

6.2 per cent

-

All ethnicities

1,857,062 2,262,124 2,875,392 3,500,485 3,992,517 115 per cent

per cent pop'n

3.0 per cent

3.4 per cent

4.1 per cent

4.7 per cent

5.2 per cent

-

per cent share

100.0 per cent

100.0 per cent

100.0 per cent

100.0 per cent

100.0 per cent

-

Males 666,069 852,445 1,088,744 1,306,878 1,474,835 121 per cent

per cent pop'n

2.4 per cent

2.9 per cent

3.6 per cent

4.3 per cent

4.9 per cent

-

Females 1,125,233 1,320,110 1,659,791 2,017,302 2,281,143 103 per cent

per cent pop'n

3.9 per cent

4.4 per cent

5.4 per cent

6.5 per cent

7.4 per cent

-

White 1,791,302 2,172,556 2,748,535 3,324,180 3,755,978 110 per cent

per cent pop'n

3.2 per cent

3.7 per cent

4.5 per cent

5.4 per cent

6.2 per cent

-

per cent share

96.5 per cent

96.0 per cent

95.6 per cent

95.0 per cent

94.1 per cent

-

Males 5,728 7,525 10,199 13,088 16,567 189 per cent

per cent pop'n

0.8 per cent

0.9 per cent

0.9 per cent

1.0 per cent

1.0 per cent

-

Females 7,760 9,920 13,246 16,776 20,908 169 per cent

per cent pop'n

1.1 per cent

1.2 per cent

1.2 per cent

1.2 per cent

1.2 per cent

-

Black 13,488 17,446 23,445 29,863 37,475 178 per cent

per cent pop'n

1.0 per cent

1.0 per cent

1.1 per cent

1.1 per cent

1.1 per cent

-

Table 2-17

2010 2020 2030 2040 2050 per cent increase 2050/2010

per cent share

0.7 per cent

0.8 per cent

0.8 per cent

0.9 per cent

0.9 per cent

-

Males 18,380 25,888 35,836 48,402 62,078 238 per cent

per cent pop'n

1.3 per cent

1.4 per cent

1.6 per cent

1.7 per cent

1.8 per cent

-

Females 20,557 27,976 38,110 51,214 65,209 217 per cent

per cent pop'n

1.5 per cent

1.6 per cent

1.8 per cent

2.0 per cent

2.1 per cent

-

Asian 38,937 53,864 73,946 99,616 127,286 227 per cent

per cent pop'n

1.4 per cent

1.5 per cent

1.7 per cent

1.8 per cent

2.0 per cent

-

per cent share

2.1 per cent

2.4 per cent

2.6 per cent

2.8 per cent

3.2 per cent

-

Males 5,689 8,742 14,349 22,898 34,687 510 per cent

per cent pop'n

0.7 per cent

0.8 per cent

0.9 per cent

1.0 per cent

1.1 per cent

-

Females 7,646 11,291 18,305 29,147 44,087 477 per cent

per cent pop'n

1.0 per cent

1.0 per cent

1.2 per cent

1.3 per cent

1.3 per cent

-

Other 13,335 20,033 32,654 52,045 78,774 491 per cent

per cent pop'n

0.8 per cent

0.9 per cent

1.0 per cent

1.1 per cent

1.2 per cent

-

per cent share

0.7 per cent

0.9 per cent

1.1 per cent

1.5 per cent

2.0 per cent

-

Source: Access Economics modelling.

Table 2-18: Projection of partial sight and blindness (<6/12) by disease type, UK (people), 2010 to 2050

AMD Cataract DR Glaucoma

RE Other

2010 16.8 per cent

13.7 per cent

3.4 per cent

5.3 per cent

53.3 per cent

7.4 per cent

2020 17.9 per cent

14.0 per cent

3.2 per cent

5.2 per cent

52.2 per cent

7.4 per cent

2030 19.6 per cent

14.5 per cent

2.8 per cent

5.2 per cent

50.4 per cent

7.4 per cent

2040 21.3 per cent

14.9 per cent

2.5 per cent

5.0 per cent

48.9 per cent

7.4 per cent

2050 22.2 per cent

15.2 per cent

2.3 per cent

5.0 per cent

47.8 per cent

7.4 per cent

Cases2010 312,789 254,357 64,035 98,368 989,952 137,5602050 887,178 605,875 93,405 200,875 1,909,44

2295,742

per cent change

184 per cent

138 per cent

46 per cent

104 per cent

93 per cent

115 per cent

Source: Access Economics modelling.

3. Health Care System ExpenditureThere are four publicly funded health care systems in the UK, which is collectively known as the NHS. These include the NHS England, NHS Wales, NHS Scotland, and Health and Social Care in Northern Ireland. The Department of Health has responsibility for the NHS in England, the Welsh Department of Health and Social Services has responsibility for the NHS in Wales, the Scottish Government Health Department has responsibility for the NHS in Scotland and the Government of Northern Ireland has responsibility for public health in Northern Ireland.

The most comprehensive health care system expenditure data is Reference Costs collected by the Department of Health in England. Reference Costs publications (DoH, 2008) show inpatient and outpatient data on average unit costs and activity levels for a wide range of health care services within a given year (2006-07 is the most recent publication). Specifically, data is provided on: the average cost of an episode, an interquartile range of episodic costs,

and a high/low range of episodic costs; and

the number of episodes, attendances, and average bed days.

Data is collected from Primary Care Trusts and NHS Trusts in England as part of the National Programme Budgeting project. Trusts provide the Department of Health with estimates of annual expenditure for 23 different programs using a systematic classification of acute care interventions into distinct clinical categories. Of these programs, 20 are based on International Classification of Disease (ICD v.10) chapters. The remaining 3 categories are intended to catch all other expenditure. Reference Cost data covers services provided in hospitals, in the community and other settings, and paramedic services provided by Ambulance NHS Trusts.

Reference Cost data has been used extensively within cost effectiveness analysis studies in the UK. The Department of Health also uses the data to inform the Payments by Results (PbR) tariff, Programme Budgeting data, and Schedule 5 of the Department’s Resource Accounts. Reference Costs data are also used by other government departments, for example The Office of National Statistics uses it to derive NHS efficiency measures (DoH, 2008).

In 2006-07, Reference Cost data covered £41 billion of NHS expenditure based on costs collected from over 400 NHS provider organisations (DoH, 2008). Health care services within the Reference Cost data are broken down into Health Resource Groups (HRGV.4). HRGs have been designed at a spell level covering a patient’s whole stay from admission to discharge, although only Finished Consulted Episode (FCE) data has been published. A FCE is a continuous period of inpatient care administered by a particular consultant within a single hospital provider. If another consultant takes responsibility for the patient, or the patient is transferred to another hospital, then a new FCE will commence. Data items within FCEs are entered from the patient’s notes onto the hospital’s administration system by people who are trained in clinical coding. It includes primary and secondary diagnoses (coded using ICD-10), information regarding the patients demographics and clinical data relating to the patient’s stay.

Reference Cost data is sub-divided into areas of particular interest, by service (elective inpatients, non-elective inpatients, day cases, and outpatients) and provider type. HRGs are designed to group episodes that are clinically identifiable and consume similar amounts of resources. This provides the opportunity to collect detailed information on the health care system expenditure relating to eye conditions that lead to partial sight and blindness.

Not all health system expenditure relating to partial sight and blindness has been captured by the Reference Cost publications. Importantly they do not provide information on costs relating to partial sight and blindness and residential aged care, allied health care, research relating to eye disease, health administration costs and other costs. For these estimates a ‘bottom up’ approach was constructed using additional sources of data.

There are a variety of direct and indirect costs associated with partial sight and blindness within the health care system. Costs investigated within this section relate to partial sight and blindness of the UK adult population (?18 years), and include: hospital inpatient expenditure; non-admitted expenditure (outpatient costs and community services); prescribing within a primary and secondary care environment; general ophthalmic services (eye examinations and corrective vision aids); expenditure associated with injurious falls attributable to partial sight and

blindness; research and development; aged care and community care sector; and capital and administration expenditure.

All costs relating to eye disease that cause partial sight and blindness have been estimated within this chapter.

3.1 Hospital Recurrent ExpenditureReference Cost data contain 35 HRG codes that specifically related to eye disease. In order to determine hospital inpatient expenditure for each condition, each HRG code was mapped to each condition. The mapping, by HRG code, description, and the condition assigned by Access Economics is shown in Appendix A.

Hospital inpatient expenditure for England was calculated using the Reference Cost data for 2006-07 (DoH, 2008) and converted to 2008 prices. Reference Cost data is presented as number of FCEs, number of excess bed days and national average unit costs, with an interquartile range of unit costs. Within this study, national average costs were used. (Average HRG costs are actually a weighted cost derived by multiplying the cost for each procedure by the total number of episodes. This gives the total costs for each procedure, which are added together and divided by the total number of episodes for the costed codes within the HRG (DHSSPSNI, 2006)) Section B of Reference Costs data, which is assigned for Eyes and Periorbita, identifies around

£428.4 million of expenditure (in 2008 prices) on admitted care for patients whose primary diagnosis is eye-related or who have undertaken eye surgery.

Mapping the HRG codes to the conditions of interest within this study provided the opportunity to determine the total inpatient costs by condition and to split this between NHS providers (Primary care trusts and NHS trusts) and non-NHS providers, elective inpatient, non-elective inpatient, and day cases.

However, Reference Cost data are not split by age groups across service recipients. In order to get the proportion of episodes for non-adults, the NHS Information Centre (England), Hospital Episode Statistics for 2006-07 was used. These data break down episodes by ICD10 codes and by age groups 0-14, 15-59, 60-74, and 75+. The proportion of episodes that were undertaken on those aged 0-14 was around 3.9 per cent. However most of these episodes were concentrated within five ICD10 codes, including Convergent concomitant strabismus (H50.0), Acute inflammation of orbit (H05.0), Strabismus (H50.9), Chalazion (H00.1), and Divergent concomitant strabismus (H50.1). None of these five conditions relate to the conditions of interest within this study so it was assumed that Reference Costs for the conditions of interest did not contain those under the age of 18.

Table 3-1 shows the breakdown of hospital inpatient costs and episodes for England by condition. It is broken down into NHS providers and non-NHS providers, and elective patient, non-elective patient and day cases. Of the £428.4 million attributed to Eyes and Periorbita: £28.1 million was spent on AMD; £236.0 million was spent on Cataracts; £57.4 million was spent on Diabetic Retinopathy; £11.0 million was spent on Glaucoma; £10.3 million was spent on Refractive error; and £85.7 million was spent on Other eye conditions.

As it was problematic to allocate Reference Costs data specifically relating to partial sight and blindness for those conditions classified as ‘Other eye conditions’, there is a relatively large amount of expenditure within this category. Consequently this data must be taken with caution as it also includes procedures that may not result in partial sight and blindness, for example conditions relating to adnexa of the eye. While it is recognized that ‘Other’ eye conditions makes up a significant proportion of hospital recurrent expenditure, unfortunately it could not be broken down any further than the HRG V.4 breakdown presented in Table A-1. Consequently, the only

conclusion that can be drawn from ‘Other’ expenditures is that it primarily relates to expenditure on oculoplastics, orbits/lacrimal, and ocular motility.

The proportion of expenditure for inpatient and day cases in England across conditions is shown in Figure 3-1. In total, around 55 per cent of hospital expenditure (inpatient and day cases) was spent on Cataracts. This is due to the large number of episodes associated with cataracts although the majority of this expenditure was within day cases. Diabetic retinopathy had the second largest proportion of expenditure at around 13 per cent, while AMD had the third largest at 7 per cent. Glaucoma and Refractive error make up 3 per cent and 2 per cent respectively, while ‘Other’ eye conditions make up the remaining 20 per cent.

TABLE 3-1: Hospital Recurrent Expenditure Associated With Partial Sight And Blindness In England 2008

NHS Providers

Elective inpatient

Non-elective inpatient

Day cases Othera Total (NHS

providers)Condition £million £million £million £million £millionAMD 3.11 14.70 9.72 0.51 28.04Cataracts 15.83 1.46 210.44 0.08 227.82DR 22.39 11.19 23.81 0.01 57.40Glaucoma 3.01 1.72 6.21 - 10.94Refractive error

4.14 2.33 3.76 - 10.25

Other 18.06 5.12 61.25 0.03 84.45Total 66.54 36.52 315.18 0.63 418.91Note: (a) ‘Other’ refers to regular day/night admissions and observation wards leading to be admitted.

Non-NHS Providers

Elective inpatients

Day cases Total(Non NHS providers)

Condition £ million £ million £ millionAMD 0.03 0.04 0.07Cataracts 0.57 7.62 8.19DR 0.01 - 0.01Glaucoma - 0.01 0.01Refractive error - - 0.01Other 0.07 1.17 1.24Total 0.68 8.85 9.54

Totals Expenditure EpisodesCondition £ millionAMD 28.12 36,759Cataracts 236.01 299,001DR 57.42 53,275Glaucoma 10.95 12,276Refractive error 10.25 7,926Other 85.70 99,954Total 428.44 509,192

Source: DoH (2008).

Figure 3-1: Proportion Of Recurrent Hospital Expenditure In England By Condition 2008

Inpatient %AMD 18Cataract 17Diabetic retinopathy 32Glaucoma 5Refractive Error 6Other 22

Day cases %AMD 3Cataract 68Diabetic retinopathy 7Glaucoma 2Refractive Error 1Other 19

Source: DoH (2008).

As Reference Cost data only relates to expenditure incurred within NHS England, data for inpatient expenditure within Scotland, Wales, and Northern Ireland was collected from alternate sources. Inpatient expenditure within Scotland was estimated using Health Service Costs (Costs Book) for 2006-07 (ISD, 2008). These costs are based on financial and statistical data collected

from Scottish Health Boards and published centrally by Information Services Division Scotland. Data is collected according to speciality and care setting, such as Ophthalmology expenditure. Although data is divided into inpatient and day cases, it is not broken down by condition. In order to break down total Ophthalmology expenditure into the conditions of interest, the proportion of total expenditure across conditions for England (as shown in Figure 3-1) was used.

Expenditure in 2006-07 for NHS Wales is detailed in ‘Health Statistics Wales’, an annual publication by the Welsh Assembly Government (WAG, 2008). Inpatient data is classified according to consultant’s speciality and care setting. Conditions of interest have been apportioned using Reference Costs from NHS England data. Health and Social Care (HSC) in Northern Ireland uses Reference Cost data to identify average costs for admitted care. Northern Ireland Reference Costs for 2006-07 are published by the Department of Health, Social Services and Public Safety (DHSSPSNI, 2008). HRG codes for Section B Eyes and Periorbita identifies £11.8 million (in 2008 prices) of HSC expenditure for inpatient and day cases. The same Access Economics mapping of HRG code to condition used for NHS England has been applied to Northern Ireland data.

Table 3-2 shows the breakdown of hospital recurrent expenditure for conditions relating to partial sight and blindness in Scotland, Wales and Northern Ireland while Table 3-3 provides a total breakdown of hospital recurrent expenditure for the UK.

Table 3-2: Hospital Recurrent Expenditure In Devolved Countries 2008

Table 3-2 Inpatient Day cases Total Condition £ million £ million £ millionScotlandAMD 3.12 0.96 4.08Cataracts 3.12 21.56 24.69Diabetic retinopathy 5.86 2.35 8.23Glaucoma 0.83 0.61 1.44Refractive error 1.13 0.37 1.50Other eye disease 4.06 6.17 10.24Total Scotland 18.12 32.04 50.16WalesAMD 0.86 1.51 2.37Cataracts 0.86 13.52 14.38Diabetic retinopathy 1.62 3.17 4.79Glaucoma 0.23 0.6 0.83Refractive error 0.31 0.56 0.87Other eye disease 1.12 4.84 5.96Total Wales 5.00 24.22 29.23Northern IrelandAMD 0.33 0.24 0.57Cataracts 0.61 5.14 5.76Diabetic retinopathy 0.79 1.52 2.31Glaucoma 0.12 0.16 0.28Refractive error 0.12 0.03 0.16Other eye disease 0.81 1.88 2.68

Source: NHS Reference Costs Collection 2006-07 and Access Economics calculations.

Table 3-3: Hospital Recurrent Expenditure In The UK 2008

Table 3-3 Inpatient Day cases TotalCondition £ million £ million £ millionAMD 22.79 12.54 35.33Cataracts 22.38 259.20 281.58Diabetic retinopathy 41.96 30.04 72.00Glaucoma 5.91 7.66 13.57Refractive error 8.08 4.77 12.85Other eye disease 29.11 75.11 104.22Total 130.23 389.33 519.55


In addition to hospital expenditure undertaken by the NHS, there are a significant number of procedures to reduce partial sight and blindness funded by the private sector. This expenditure also needs to be included in the total cost of partial sight and blindness to the economy.

Unfortunately there is limited data on the number of procedures related to partial sight and blindness that are funded privately. Evidence suggests that a significant number of cataract procedures are undertaken in the private sector to avoid the waiting time for the procedure to be undertaken within the NHS. In a survey of 215 acute independent hospitals with operating departments in England and Wales conducted in 1997-98, Williams et al (2000) estimated that 16.5 per cent of lens operations were privately funded while 7.5 per cent of other eye operations were privately funded. Within this study it has been assumed that the proportion of elective treatments purchased privately has remained constant over the last decade, and that the cost of private procedures is the same as if funded by the NHS. This allowed the cost of procedures from the Reference Cost data to be used to estimate the total cost of private procedures.

The total cost of admitted care relating to partial sight and blindness (including public and private expenditure) was calculated by multiplying total cost funded by the NHS (as presented in Table 3-1 and Table 3-2) for each condition by the reciprocal of the proportion of NHS expenditure related to lens operations (cataracts) and other eye operations, both derived from Williams et al (2000).( NHS expenditure was assumed to be 83.5% (100%-16.5%) of total funding for lens operations and 92.5% (100%-7.5%) of total

funding for all other eye procedures.) The cost attributable to private funding was derived by subtracting the total cost of admitted care by the total cost funded by the NHS.

The estimated private cost for admitted care related to partial sight and blindness was estimated as £73.17 million (in 2008 prices). This is shown in Table 3-4, broken down by condition and country. As this cost only relates to admitted care, it does not include costs associated with any assessment visits that may occur before or after a procedure. These types of private costs are captured in Section 3.2.

Table 3-4: Private Hospital Expenditure In The UK Related To Partial Sight And Blindness 2008

Table 3-4 England Scotland Wales Northern Ireland

Total

Condition £ million £ million £ million £ million £ millionAMD 2.28 0.33 0.20 0.04 2.85Cataracts 46.64 4.88 1.17 1.14 53.82Diabetic retinopathy

4.65 0.66 0.38 0.19 5.89

Glaucoma 0.89 0.11 0.06 0.02 1.10Refractive error

0.83 0.12 0.07 0.01 1.04

Other eye disease

6.95 0.83 0.49 0.22 8.47

Total 62.24 6.94 2.37 1.62 73.17


3.2 Non-Admitted ExpenditureNon-admitted expenditure consists of outpatient costs and other community services, including paramedic services, consultant led multi-professional and outpatient face to face attendances, and non-consultant led multi-professional and outpatient face to face and non face to face attendances.

Outpatient costs for England were sourced from the Reference Costs data and are shown in Table 3-5. These are broken down into outpatient services and observation wards provided by NHS service providers, and outpatient services not provided by NHS service providers. As these services were categorised by HRG codes, a split into eye conditions could be made using

the concordance shown in Appendix A. In total, around £21.4 million (in 2008 prices) was spent in 2006-07 on these types of services.

‘Other community services’ for England were also sourced from the Reference Costs data and totalled £383.3 million (in 2008 prices) (as shown in Table 3-6). These are broken down into 13 different types of services. Unfortunately, Reference Cost data does not split them into HRG codes, instead it uses a more general coding such as Orthoptics, Eye problems / Injuries, Ophthamology, and Medical Ophthamology. It also provides expenditure data for Paediatric Ophthamology although this was not included in the total expenditure as this study is concerned with adults.

In order to split ‘Other community services’ across eye conditions, the proportion of expenditure for each eye condition within ‘Outpatient costs’ was applied to the total expenditure for ‘Other community services’. This implicitly assumes that the breakdown in expenditure across eye conditions for outpatient costs are the same, or similar, to other community services. Expenditure for ‘Other community services’ by condition is shown in Table 3-7.

For Scotland, Wales, and Northern Ireland, total expenditure for outpatient and other community services was collected from each countries NHS publicly available data source. Unfortunately these data sources do not break down these types of costs into the same detail for England. Consequently expenditure between outpatient costs and other community services costs as defined by NHS England could not be directly determined for devolved nations other than England.

Table 3-5: Outpatient Costs For England 2008

Table 3-5 Outpatients Observation wards

Total outpatient - NHS

Total outpatient – non NHS

Total outpatient NHS and non NHS

Condition £ million £ million £ million £ million £ millionAMD 0.00 0.65 0.65 0.01 0.65Cataracts 1.74 0.00 1.74 1.72 3.47Diabetic retinopathy

10.31 0.01 10.32 0.00 10.32


2.26 0.05 2.32 0.00 2.32

Other eye disease

3.77 0.00 3.77 0.00 3.77

Total 18.91 0.71 19.63 1.73 21.36Source: NHS Reference Costs Collection 2006-07.

Table 3-6: Other Outpatient Services Costs For England, By Service Type 2008Table 3-6 £ millionOther community services 1.76Paramedic services 1.66Consultant led first attendance multi-professional face to face 1.75Consultant led first attendance outpatient face to face 133.94Consultant led follow up attendance multi-professional face to face

0.02

Consultant led follow up attendance outpatient face to face 205.78Consultant led follow up attendance outpatient non face to face 0.03Not consultant led first attendance multi-professional non face to face

0.00

Not consultant led first attendance outpatient face to face 12.73Not consultant led first attendance outpatient non face to face 0.00Not consultant led follow up attendance multi-professional face to face

0.45

Not consultant led follow up attendance outpatient face to face 24.77Not consultant led follow up attendance outpatient non face to face

0.39

Total 383.30Source: NHS Reference Costs Collection 2006-07.

Table 3-7: Other Outpatient Services Costs For England, By Condition 2008

Table 3-7 £ millionAMD 11.74Cataracts 62.23Diabetic retinopathy 185.11Glaucoma 14.90Refractive error 41.60Other eye disease 67.71Total 383.30Source: NHS Reference Costs Collection 2006-07.

To allocate expenditure across eye conditions for Scotland, Wales, and Northern Ireland, the expenditure proportions across eye conditions for England were applied to the total outpatient and other community services expenditure for each country. Total non-admitted expenditure (outpatient and community services costs) by eye condition for each country was estimated to be £467.0 million (in 2008 prices) and is shown in Table 3-8.

Table 3-8: Outpatient And Other Community Services NHS Expenditure For The UK 2008

Table 3-8 England Scotland Wales N.I. TotalCondition £ million £ million £ million £ million £ millionAMD 12.39 0.90 0.76 0.34 14.39Cataracts 65.70 4.76 4.02 1.81 76.29Diabetic retinopathy

195.43 14.15 11.96 5.40 226.94


43.92 3.18 2.68 1.21 50.99

Other eye disease

71.48 5.18 4.37 1.98 83.01

Total 404.65 29.31 24.75 11.18 466.99Source: Access Economics calculations.

There are significant outpatient services that are also paid by the private sector. These mainly relate to pre and post procedural assessment visits. However, there are limited data relating to the amount of private funds spent on outpatient care. Consequently it has been assumed that the proportion of

total expenditure for outpatient services funded by the NHS is 83.5 per cent for cataract and 92.5 per cent for all other eye conditions, derived from Williams et al (2000). Total outpatient expenditure funded by the private sector is estimated to be £38.10 million (in 2008 prices). This is shown in Table 3-9, broken down by condition and country.

Table 3-9: Outpatient And Other Community Services Private Expenditure For The UK 2008


15.85 1.15 0.97 0.44 18.40


3.56 0.26 0.22 0.09 4.13

Other eye disease

5.79 0.42 0.35 0.16 6.73


Non-admitted expenditure for ophthalmic disease also includes expenditure on GP services. GP expenditure is likely to represent a significant cost as most eye diseases are managed by GPs. In a survey of GPs in Nottingham, Sheldrick et al (1993) estimated around 1.5 per cent of all GP consultations were related to eye problems, while in a survey of GPs in London, McDonnell (1988) estimated that 2.3 per cent of all consultations were associated with ocular symptoms. However, most of the ophthalmic disease managed by GPs relate to bacterial conjunctivitis, allergic conjunctivitis, meibomian cyst and blepharitis, accounting for around 70 per cent of consultations (McDonnell 1988)

The funding of GPs and their premises are not within the remit of Reference Costs. Unfortunately there were not sufficient data to allow the estimation of the expenditure on GP consultations. Although the majority of GP costs associated with ophthalmic disease are not associated with eye diseases relating to this study, there is still likely to be a significant cost. Consequently total non-admitted expenditure presented in this section should be considered a conservative estimate.

3.3 Prescribing Expenditure In Primary CareAccording to the NHS Information Centre, community prescribing reached £8.75 billion in 2006-07 (NHSIC, 2008). As part of this total, NHS expenditure on prescriptions for eye therapy was around £138.7 million, or 1.6 per cent. Although this estimate includes prescriptions written in hospitals and dispensed in the community, it is likely to be an underestimate of the actual total cost of prescribing expenditure in primary and secondary care as it does not include prescriptions dispensed in hospitals.

Prescribing expenditure for the eye was further broken down according to the British National Formulary (BNF) Classification, which is shown in Table 3-10. Around £94.5 million (in 2008 prices), or 71 per cent of total prescribing costs for the eye, was spent towards the treatment of glaucoma, while around £22.3 million, or 17 per cent of total prescribing costs for the eye went towards miscellaneous ophthalmic preparations such as ocular diagnosis, peri-op preparations and photodynamic treatment, tear deficiency, and eye lubricant and astringent (NHSIC, 2008)

Table 3-10: Community Eye Prescription Expenditure For England 2008

Classification £ million11.3 Anti-infective eye preparations 7.0411.4 Corticosteroids and other anti-inflammatory preparations

10.88

11.5 Mydriatics and cycloplegics 0.2111.6 Treatment of glaucoma 94.4811.7 Local anaesthetics 0.00411.8 Miscellaneous ophthalmic preparations

22.27

Total Eye 134.89Source: NHSIC (2008).

Once the expenditure of treating glaucoma was removed from the total prescribing expenditure, the remainder of the expenditure was split between all other conditions. Rather than using an equal split the prescribing costs were split according to the proportion of total separations for each condition, as shown in Table 3-1. This was on the assumption that most other prescribing costs were associated with surgery, regardless of the type of surgery undertaken. Prescribing costs between all conditions are shown in Table 3-11.

Table 3-11: Community Eye Prescription Expenditure For England By Prescription 2008

Condition £ millionAMD 2.85Cataracts 24.41Diabetic retinopathy 4.34Glaucoma 94.50Refractive error 0.64Other eye disease 8.15Total Eye 134.90Source: NHSIC (2008) and Access Economics calculations.

Expenditure in primary care prescribing outlined above only includes expenditure within England. Although devolved nations data includes total prescribing costs for primary care they do not provide enough information to break the totals down into specific conditions. Data for Scotland and Northern Ireland is provided for prescribing expenditure related to glaucoma and prescribing related to towards miscellaneous ophthalmic preparations. Data for Wales only includes total prescribing costs for the eye. Consequently a proportional split across eye conditions for England was applied to the Wales data to estimate primary prescribing costs across conditions.

Total public prescribing expenditure within primary care was estimated at £158.12 million (in 2008 prices), as shown in Table 3-12 across condition and country. It must be noted that this may be an underestimate of future prescribing expenditure as it does not include the expected increase in costs associated with the approval of Lucentis by the National Institute for Clinical Excellence (NICE) in August 2008.

Table 3-12: Public Expenditure For Prescribing Within Primary Care 2008

Table 3-12 England Scotland Wales N.I. TotalCondition £ million £ million £ million £ million £ millionAMD 2.85 0.19 0.20 0.10 3.34Cataracts 24.41 1.64 1.70 0.86 28.61Diabetic retinopathy 4.34 0.29 0.30 0.16 5.09Glaucoma 94.50 8.06 6.56 1.66 110.78Refractive error 0.64 0.06 0.04 0.02 0.76Other eye disease 8.15 0.54 0.57 0.29 9.55Total 134.90 10.78 9.37 3.09 158.12Source: Access Economics calculations.

The estimate of public prescribing expenditure makes up one component of total prescribing costs as there will also be private expenditure through copayments. Unfortunately there was insufficient utilisation and cost unit data to estimate this type of prescribing expenditure.

3.4 General Ophthalmic ServciesGeneral Ophthalmic Services (GOS) provide free preventative and corrective eye care for children aged 0 to 15 years old, students aged 16 to 18 years old, people aged 60 and over, people on low incomes and those suffering from, or pre-disposed to, eye disease. The service comprises eye tests, vouchers for spectacles (new and replacements) and eye test domiciliary visits.

In England, expenditure for GOS was sourced from the NHS England resource budget (DoH, 2007). In 2006-07 the total cost was £380.0 million. For the same period, expenditure in Scotland was £66.7 million (ISD, 2008), expenditure in Wales was £24.1 million (WAG, 2008a), and for Northern Ireland expenditure totalled £16.1 million (DHSSPSNI, 2008). These expenditures relate to sight tests, vouchers for a pair of glasses, services provided by ophthalmic medical practitioners, domiciliary visits, and repairs to glasses.

As total GOS expenditure includes costs associated with children, expenditure related to children was removed to ensure GOS expenditure

related to adults only. A report on general ophthalmic services activity in England and Wales for 2006-07 provides a breakdown of service expenditure by broad age groups, which includes children aged 0 to 15 and students aged 16 to 18 (ONS, 2007). Data on activity is provided by Primary Care Trusts in England and Local Health Boards in Wales. It shows that expenditure on eye tests and vouchers for spectacles (new and replacements) for people aged between 0 and 18 years of age was 24.9 per cent and 33.8 per cent respectively. Consequently total GOS expenditure for England, Wales, Scotland, and Northern Ireland were reduced using these proportions.

Total public GOS expenditure for eye tests and optical vouchers was estimated as £358.21 million as shown in Table 3-13. As expenditure on vouchers relates to spectacles (new and replacements), it was assumed that this total cost is due to Refractive Error. Expenditure for eye tests was broken down into specific eye conditions using data published by the Information Services Division (ISD) Scotland for the year ending March 2008 (ISD, 2008). This data identifies the number of eye tests carried out by NHS Scotland according to patient type and eye condition. Table 3-14 shows the data from ISD Scotland with each condition listed given a proportion of the total.

The proportion of eye tests by condition (as shown in Table 3-14) was used to split eye test expenditure into conditions for each country. The category ‘Visually impaired’ and the category ‘None of the above’ was apportioned to Refractive Error. Total public GOS expenditure by condition for each country is shown in Table 3-15.

Table 3-13: Public GOS Expenditure On Persons ≥18 Years Of Age 2008

Table 3-13 Vouchers Eye tests TotalRegion £ million £ million £ millionEngland 129.76 149.23 278.98Scotland 15.57 34.23 49.80Wales 8.03 9.65 17.67Northern Ireland 6.38 5.37 11.75Total 159.74 198.47 358.21Source: DoH (2007), ISD (2008), WAG (2008a), DHSSPSNI (2008), ONS (2007), and Access Economics calculations.

Table 3-14: Number Of Eye Conditions In Scotland, By Condition 2007-08

Table 3-14 Number ProportionVisually impaired 12,758 0.01Cataracts 206,271 0.12Diabetic retinopathy 96,032 0.06Glaucoma 99,118 0.06External eye disease 40,512 0.02AMD 68,129 0.04None of the above 1,184,585 0.69Total 1,707,405 1.00Source: ISD (2008).

Table 3-15: Public GOS Expenditure On People ≥18 Years Of Age, By Condition 2008


8.39 1.93 0.54 0.30 11.17


234.41 39.58 14.79 10.14 298.92

Other eye disease

3.54 0.81 0.23 0.12 4.71


Not only are GOS paid for through public funds, a significant proportion of costs are borne by individuals through out-of-pocket expenses. The Sight Tests Volume and Workforce Survey estimated that that around 31.4 per cent of sight tests in the UK were paid for privately in 2005-06 (ONS, 2007). As public funds can be used for sight tests for those people aged 60 and over and those suffering from, or pre-disposed to, eye disease, it was assumed that eye tests paid out-of-pocket are mostly for Refractive Error. It is also likely that the proportion of people who pay for spectacles is similar to the proportion of people who pay for eye tests. This is because the same conditions must be met for public funding.

The total public cost for Refractive Error for those aged 18 years and over was estimated to be £298.9 million (see Table 3-15), which includes expenditure on eye tests and vouchers for spectacles. Assuming this expenditure represents 68.6 per cent of total expenditure for Refractive Error, it is estimated that private expenditure on eye tests and spectacles within the UK was around £125.8 million. The breakdown of this expenditure by expenditure type and country is shown in Table 3-16. There has been no private expenditure for eye tests assigned to Scotland as the Scottish population started to receive free eye tests in April 2006. ( http://www.scotland.gov.uk/News/Releases/2006/03/31123423, accessed 07 January 2009 )

Table 3-16: Private GOS Expenditure By Persons ≥18 Years Of Age 2008

Table 3-16 Spectacles Eye tests TotalEngland 59.39 47.90 107.30Scotland 7.13 0.00 7.13Wales 3.68 3.10 6.77Northern Ireland 2.92 1.72 4.64Total 73.12 52.72 125.83Source: Access Economics calculations.

3.5 Expenditure Associated With Injurious FallsSight loss has a profound impact on wellbeing. It can shorten life, increase the risk of other conditions, restrict social participation and independence and impair physical and mental health. Moreover, the cost of sight loss is not limited just to the treatment cost of the various conditions that underlie it. Brody et al (2001) showed that: 78 per cent of subjects reported having at least one comorbid condition in

addition to the sight loss for which he or she was receiving medical care; the mean number of comorbid conditions reported was 1.33, suggesting

an attributable fraction for sight loss relative to all conditions of 42.9 per cent;

the most frequently reported comorbid conditions were hypertension (32 per cent), heart disease (14 per cent), thyroid disorder with medication (10 per cent) and cancer (8 per cent); and

the depressed group had a higher mean number of comorbidities at 1.67 compared to 1.17 in the non-depressed group.

The only conditions that were statistically significant and likely to be causally related to partial sight and blindness were falls and depression. These

http://www.scotland.gov.uk/News/Releases/2006/03/31123423

mechanisms can also increase mortality for people with partial sight and blindness.

Older people are more at risk of falls that often cause injuries and additional health expenditures. Many studies have examined the factors underlying increased propensity to fall in the elderly and several have found a significant link between falls and sight loss. For example, Coleman et al (2004) reported that women with declining visual acuity had 1.85 to 2.08 odds of experiencing a fall. In a review of 31 studies on the risks and types of injuries associated with sight loss, Legood et al (2002) suggest that those with sight loss are 1.7 times more likely to have a fall and 1.9 times more likely to have multiple falls. They also suggest that the odds of a hip fracture are between 1.3 and 1.9 times greater for those with sight loss.

A summary of some key studies regarding vision loss and falls or fractures is presented in Table 3-17. Generally, these studies distinguish between the occurrence of accidental falls and the expensive and morbid complications of a hip fracture resulting from some falls. On average across all the studies, the odds ratio (OR) of accidental falls is 1.59 while, for those with mild or moderate sight loss, the OR of hip fracture is 1.83 and for the blind it is 3.95.

Sight loss can also cause depression. Most studies find prevalence rates of depression in elderly populations with sight loss between 25 per cent to 45 per cent (Burmedi et al, 2002). Within the general elderly population, less than 20 per cent have mild dysphoria with less than 5 per cent suffering from severe depression. It is again necessary to control for other comorbidities. Table 3-18 provides a review of findings regarding the prevalence of depression within those who experience sight loss. Comparing estimated risk of depression from these studies, the relative risk of depression is estimated to be around 3.5 times higher. However, as there was not enough adequate Reference Cost data on health care system expenditure relating to depression this cost has not been estimated.

Table 3-17: Odds Ratio Of Falls And Hip Fractures Due To Sight Loss

Table 3-17

Visual acuity Odds ratios Source

1 loss ≥ 2 lines compared to <2 lines

OR of multiple falls = 1.43

Coleman, 2004

2 <6/12 OR of multiple falls = 1.75

Koski, 1998

3 poor distance vision OR of multiple falls = 2.3

Koski, 1998

4 <6/9 in either eye OR of hip fractures = 1.73

Felson et al, 1989

5 ≤ 6/30 in both eyes OR of hip fractures = 2.17

Felson et al, 1989

6 ≤ 6/15 compared to >6/9 OR of hip fracture = 2

Dargent-Molina, 1996

7 no association found between VA and fractures

Cumming et al, 1995

8 ≤ 6/18 OR of hip fracture = 8.4

Ivers et al, 1998


Klein et al, 1998

10 ≤ 60/60 (face recognition) OR of hip fracture = 3.1

de Boer et al, 2004


Grisso et al, 1991


Ivers et al, 2000

13 <6/12 better eye OR of fall at home = 0.98

Vu et al, 2005

OR hip fracture = 1.50

<6/12 worse eye OR fall at home = 2.86OR hip fracture = 1.80

Table 3-18: Prevalence Of Depression In Those With Sight Loss

Table 3-18

Visual acuity Odds ratios Source

1 loss ≥ 2 lines compared to <2 lines

OR of multiple falls = 1.43

Coleman, 2004

2 <6/12 OR of multiple falls = 1.75

Koski, 1998

3 poor distance vision OR of multiple falls = 2.3

Koski, 1998

4 <6/9 in either eye OR of hip fractures = 1.73

Felson et al, 1989

5 ≤ 6/30 in both eyes OR of hip fractures = 2.17

Felson et al, 1989

6 ≤ 6/15 compared to >6/9 OR of hip fracture = 2

Dargent-Molina, 1996

7 no association found between VA and fractures

Cumming et al, 1995


Ivers et al, 1998


Klein et al, 1998


de Boer et al, 2004


Grisso et al, 1991


Ivers et al, 2000

13 <6/12 better eye OR of fall at home = 0.98

Vu et al, 2005

OR hip fracture = 1.50

<6/12 worse eye OR fall at home = 2.86OR hip fracture = 1.80

Source: Burmedi et al (2002).

Health care system expenditure due to injury relating to partial sight and blindness was estimated using the methodology presented in Scuffham et al (2002), a study developed to find costs and incidence of falls associated with

partial sight and blindness in the UK. Within their study the cost of falls attributable to sight loss are estimated by assuming that people with sight loss would have the same rate of falls as people with no sight loss if their sight was corrected. The same assumption was made within this study.

Hospital Episodes Statistics (HES) is an online data source which collects details for all hospital episodes in England (NHSIC, 2008a). Admissions according to age and the total number of emergency admissions are recorded by ‘external cause’ meaning that the original cause of injury is recorded whenever it is possible to do so.

To record ‘external cause’, ICD-10 codes are used. There are 19 diagnostic codes assigned to alternative types of falls for example, slipping, tripping or tumbling, or falling from a bed or chair. However not all of the diagnosis codes are attributable to partial sight and blindness, so those that are likely not to be the result of partial sight and blindness were omitted. (Categories omitted include: W00 Fall on same level involving ice and snow, W02 Fall involving ice-skates skis roller-skates or skateboards, W03 Other fall same level due collision/pushing by another person, W04 Fall while being carried or supported by other persons, W05 Fall involving wheelchair W06 Fall involving bed W07 Fall involving chair W08 Fall involving other furniture W09 Fall involving playground equipment, W11 Fall on and from ladder, W12 Fall on and from scaffolding, W13 Fall from out of or through building or structure, W14 Fall from tree, W15 Fall from cliff, W16 Diving/jumping into water causing injury other than drowning or submersion)

To calculate the total cost associated with falls (for all people not just those with sight loss), the number of FCEs, day cases and A&E attendances were multiplied by the weighted average costs for these services. A weighted average cost for FCEs was derived from non-elective inpatient HRG Reference Cost data for the three HRG codes attributed to falls (WA23V, WA23X, and WA23Y), estimated as £1,418.9. A weighted average cost for day cases was derived from the same HRG codes for Reference Cost data regarding Day Cases, and equated to £425.3. As A&E Reference Cost data is not broken down into HRG codes for falls, an average cost for attendance was derived from Reference Cost data relating to minor injury service leading to admitted. This equated to £76.7 per attendance.

As patients can arrive to A&E either by their own transport or using a paramedic service, the proportion of those arriving by ambulance was estimated as 40.9 per cent (Calculated by dividing the total number of paramedic services (excluding transfers) by the total number of A&E attendances, both sourced from the Reference Cost data for 2006-07). This

proportion was applied to the total A&E episodes related to falls to derive an estimate of the total number of ambulance episodes related to falls. A weighted average FCE cost associated with ambulance services was derived from Reference Costs relating to paramedic services associated with falls. The weighted average cost was calculated across services provided by urban ambulance NHS Trusts for categories A, B, and C. This equated to £180.

Table 3-19 shows the number of episodes relating to admissions, A&E attendances, day cases and ambulance services. As falls within the HES relate to England these were scaled up by a factor of 1.19 to represent falls associated with the UK population. (Scaling was calculated by dividing the total UK population by the England population, which were both derived form the population model use in Section 2 of this report.)

Table 3-19: Number Of Episodes Related To Falls For Total UK Population, 2006-07

Fall type 0-14 15-59 60-74 ≥75 TotalAdmitted 14,714 40,999 29,888 111,462 197,062A&E 13,724 38,074 27,681 102,678 182,158Day cases 223 691 547 2,322 3,784Ambulance 10,190 27,986 20,175 73,826 132,177Total 62,148 171,120 123,577 453,766 810,612Source: NHSIC (2008a) and Access Economics calculations.

Scuffham et al’s (2002) methodology was used to determine the number of episodes attributable to partial sight and blindness. They estimated the number of falls attributable to partial sight and blindness as the difference between the estimated number of falls in the population with partial sight and blindness and the expected number of falls in this population if they did not have sight loss. Within this study, rather than using falls the different types of episodes were used (admitted, day cases, A&E, and ambulance). Following Scuffman et al (2002) this can be represented by:

Episodesk,VI = (IVI – Inon-VI) PVI

where Episodesk,VI is the number of episodes directly attributable to partial sight and blindness across the k types of episodes, PVI is the prevalence of partial sight and blindness, and Ik,VI and Ik,non-VI are the attributable fractions given by the following equations:

I k,VI = RR* [Episodes k,Total / RR* P VI + P non-VI]I k,non-VI = [Episodes k,Total / RR* P VI + P non-VI]

where Pnon-VI is the population of people without partial sight and blindness, RR is the relative risk of falls associated with partial sight and blindness, which was 1.9 (Scuffham et al, 2002) and Episodesk,Total is the known number of episodes related to falls within the population.

Table 3-20 shows the number of episodes relating to falls due to partial sight and blindness in the UK and Table 3-21 shows the associated direct health care system costs. Excluding the costs of those aged between 0 and 17 to focus on adults, the total cost of falls related to partial sight and blindness for adults was estimated as £25.1 million.

Table 3-20: Estimated Episodes Related To Falls Due To Partial Sight And Blindness In The UK 2008

Fall type 18-59 60-74 ≥75 TotalAdmitted 3,448 2,688 9,887 16,023A&E 3,202 2,490 9,113 14,805Day cases 58 49 204 311Ambulance 1,312 1,019 3,730 6,061Total 8,021 6,246 22,934 37,201Source: Access Economics calculations.

Table 3-21: Public Costs Of Episodes Related Tom Falls due To Partial Sight And Blindness In The UK 2008

Table 3-21 18-59 60-74 ≥75 TotalFall type £ million £ million £ million £ millionAdmitted 4.89 3.81 14.03 22.73A&E 0.26 0.19 0.69 1.14Day cases 0.03 0.02 0.08 0.14Ambulance 0.23 0.19 0.67 1.09Total 5.41 4.21 15.48 25.10Source: Access Economics calculations.

However, the above costs are an underestimate of the total cost associated with injurious falls related to partial sight and blindness. This is because they do not include the substantial private costs that are also expected to occur, such as wound dressings, antiseptics, and private rehabilitation services. Unfortunately data on utilisation was not available to adequately estimate these costs.

3.6 Research and DevelopmentFunding for medical R&D is channelled through three main sources in the UK, including private industry, non profit organisations, and public funds through the government (McGuire and Raikou, 2006).

The private sector contributes a significant proportion, with non-commercial medical R&D accounting for 69 per cent of total medical R&D in the UK in 2004-05 (Hargreaves, 2008). This is primarily through pharmaceutical and biotechnology companies where research is undertaken in commercial facilities. Non profit organisations (such as The Wellcome Trust, Cancer Research UK, and British Heart Foundation) contribute a large proportion, accounting for around 9 per cent of funding in 2004-05. Finally, public funding from the UK government, which includes the Medical Research Council (MRC), Higher Education Funding Councils, other government departments such as Defence, and the NHS, accounts for 23 per cent. Most of these funds are channelled through the Department of Health in England (which is managed by the National Institute for Health Research) and the research councils (Hargreaves, 2008).

As private expenditure on R&D mostly relates to pharmaceutical and biotech products, it is not expected that a large amount of funding would come from the private sector for eye and adnexa conditions. Consequently it has been assumed that all R&D funding for these types of conditions comes from non-commercial sources.

In a review of the 11 largest government and charity funders of medical research and development, Hargreaves (2008) estimated around £950 million (0.04 per cent of GDP) of non-commercial funds were spent specifically on health related R&D in the UK in 2004-05. Assuming that medical R&D has been growing at the average rate of real GDP growth of 2.6 per cent (Statistics UK, 2008), estimated total non-commercial funds expended in medical R&D is estimated to be around £1.09 billion in 2008.10 NHS R&D funding alone is expected to comprise around £703.21 million (DoH, 2007).

Direct information on the amount of medical R&D expenditure relating to specific eye conditions is limited. The Biotechnology and Biological Sciences Research Council (BBSRC) estimated that around £5.2 million was spent by their organisation on research involving studies on vision and vision diseases in 2006-07. The breakdown of R&D across research types is shown in Table 3-22. However, BBSRC is one of seven research councils that work together as Research Councils UK. In addition, it is expected that significant

expenditure in medical R&D specifically relating to eye conditions would be funded through the NHS, which needs to be accounted for if a complete estimate of R&D expenditure for sight loss is to be made.

Table 3-22: BBSRC R&D Expenditure2008

Table 3-22 Vision research Vision disease research

Total

Type of expenditure

£ million £ million £ million

Grants 4.28 0.59 4.86Institute projects 0.13 0 0.13Studentships 0.15 0.03 0.18Total 4.56 0.62 5.17Source: BBSRC personal communication, 07 November 2008.

In order to get the proportion of total R&D that specifically relates to partial sight and blindness, a breakdown of non-commercial R&D expenditure across health specific categories was used. The breakdown was sourced from Cooksey (2006), shown in Figure 3-2, where it is estimated that the proportion of non commercial UK health research funding for ear and eye conditions is around 4.5 per cent. This suggests the total medical R&D for eye and ear conditions accounted for around £48.02 million (4.5 per cent of £1.09 billion) in 2008.

As total expenditure relates to both eye and ear conditions, it was split to estimate the cost of medical R&D for partial sight and blindness. As noted by Cooksey (2006), the overall funding pattern of health categories is generally in line with the burden of disability, which is measured by the UK DALYs for each health category. For example, ear and eye category accounts for around 4.5 per cent of total non commercial funding and similarly accounts for around 4.5 per cent of the total burden of disease within in Figure 3-2.

To breakdown the ear and eye category into its component parts, DALYs by cause, sex, and age in high income countries were sourced from the WHO Global Burden of Disease project (WHO, 2006). The breakdown for sense organ disorders are shown in Table 3-23.

Figure 3-2: Breakdown of Non-Commercial UK Health Research Funding, 2003-04 in percentages

Condition DALY Public SpendSkin 0.25 0.5Congenital 1 1.2Renal and Urogenital 1.1 1.2Respiratory 9.25 1.5Oral and Gastrointestinal

5.75 2.25

Reproductive Health 1.5 4.25Ear, Eye 4.5 4.75Musculoskeletal 4.25 3.75Metabolic and Endocrine

3.25 4.25

Blood, Cardiovascular, Stroke

17 8.5

Infection 4.5 13Neurological, Mental Health

26 28.5

Cancer 15.5 18.75

Source: Cooksey (2006).

Table3-23: DALYS For Sense Organ Diseases, By Cause And Gender, 2001

Table 3-23 Males Females Total Proportion of total

Condition 000s 000s 000s %Glaucoma 107 161 268 3.5Cataracts 201 292 493 6.4Vision disorders, age related

611 915 1,525 19.9

Hearing loss, adult onset

2,669 2,718 5,387 70.2

Other sense disorders

1 1 3 0.04

Total 3,589 4,087 7,676 100.0

Source: WHO (2006).

Based on the breakdown in DALYs, it is estimated that expenditure on medical R&D for eye conditions is around 29.8 per cent of the total medical R&D for ear and eye conditions. Consequently, total expenditure for eye conditions is estimated to have been around £14.0 million in 2008.

As the Global Burden of Disease project does not specifically itemise DALYs associated with diabetic retinopathy and refractive error, it is problematic to break down the total R&D expenditure using DALYs extracted from WHO (2006) into the eye conditions under investigation within this report. Instead it was assumed that the relative burden of disease between eye conditions is similar in Australia and the UK. This allowed us to use a detailed Australian report on the burden of disease (Begg et al, 2007), which is based on the WHO methodology used to calculate burden of disease, to further breakdown the proportion of DALYs across eye conditions. The final breakdown of medical R&D across conditions for the UK is shown in Table 3-24. Although most R&D relating to partial sight and blindness is undertaken in England there were no reliable data available to split between nations.

Table 3-24: Breakdown of Non-Commercial UK Health Research Funding 2008

Table 3-24 % of DALY(see note a) Medical R&D expenditure

Condition £ million £ millionAMD 25.17 3.42Cataracts 5.08 0.73Diabetic retinopathy and other eye disease

24.76 3.32

Glaucoma 7.98 1.04Refractive error 40.61 5.49Total 103.60 13.99Note: (a) Proportion of total DALYs associated with eye conditions were derived from Begg et al (2007) and relate to the Australian population. It is assumed that the proportion of the burden of disease across eye conditions in Australia is similar to the UK.Source: Begg et al (2007) and Access Economics calculations.

3.7 Residential Care And Community Care SectorsPublicly funded social services in the UK are provided at a local level by Councils with Social Services Responsibilities (CSSRs). Some social services are provided by the NHS but the majority of services are provided by councils.

It is common for the costs of social care to be shared by the local council and person receiving care. Contributions are paid to councils and recorded as revenue. The size of the contribution made by each person receiving services is determined by financial means test which is based on income, capital and assets.

In order for a person to qualify for social care an assessment of needs is carried out by a health visitor. Councils are obliged to carry out one or continual assessments in a timely manner whenever a person, relative or healthcare professional requests it. Assessments are based on a person’s ability to live independently, their physical safety, level of physical and mental health, involvement in education/work/learning and the availability of social/familial support.

Community services are categorised as either community or residential based. Community-based services include day care, meals, home care,

overnight respite, short term residential, direct payments, professional support, equipment and other (which primarily includes transport costs). Residential care covers independent sector residential care, local authority residential care and nursing care.

Community care in England is provided through Personal Social Services (PSS). Expenditure for PSS is broken down into client groups for children and families, people aged 65 and over and adults aged 18 to 64 with mental, learning or physical disabilities (which includes partial sight and blindness). The latter two client groups were relevant to this study.

A report by the ONS estimates that PSS expenditure in England totalled approximately £20.12 billion in 2006-07 (ONS, 2008a). Table 3-25 shows the breakdown of expenditure for the relevant client groups. Expenditure on people aged 65 years and over totalled around £8.7 billion and expenditure for physically disabled adults totalled around £1.4 billion.

Table 3-25: Expenditure On Social Services For Adults With Physical Disability And Older People In England, 2006-07

Table 3-25 Disabled adults 18-64

Older people (≥65)

Other Total

Expenditure type

£ million £ million £ million £ million

Community-based

800 2,980 4,790 8,570

Residential care

370 4,710 3,240 8,330

Assessment and care management

250 960 2,020 3,230

Total 1,420 8,660 10,050 20,120Source: ONS (2008a).

To estimate expenditure on services, activity data for physically disabled adults and older people aged 65 and over experiencing partial sight and blindness and dual sensory loss for community-based and residential services in England was used. This data was sourced from a report by the ONS (2008b), which showed around 1.8 million people received some form of PSS care in 2006-07 and of these, around 47,000 people suffered from a partial sight and blindness while 7,300 experienced dual sensory loss. That is, around 3.0 per cent of PSS services were related to partial sight and blindness.

Estimated expenditure on community services for those with partial sight and blindness in England are shown in Table 3-26. These were calculated by multiplying the proportion of people with sight loss or dual sensory loss clients by the total expenditure for people aged 65 years and over and total expenditure for adults aged 18 to 64 with mental, learning or physical disabilities. (Although this calculation includes individuals with dual sensory loss it was assumed that partial sight and blindness was the main contributor to community-based and residential care. Consequently no adjustments were made for the contribution of any other sensory loss to care.)

Personal social services expenditure for Scotland (National Statistics, 2008), Wales and Northern Ireland (DHSSPS, 2008) was also available, although data on the consumption of services by people with sight loss is not provided. Instead, total community services expenditure for the devolved nations was multiplied by the same proportions derived from England data. Community services expenditure for partial sight and blindness across devolved nations is shown in Table 3-27.

Table 3-26: Estimated Expenditure On Community Services For Those With Sight Loss In England 2008

Table 3-26 Disabled adults 18-64

£ million

Older people (≥65)

£ million

Total£ million

Partial sight and blindnessCommunity-baseda

12.64 105.26 117.90

Residential care (see note a)

1.86 84.43 86.30

Dual sensory loss Community-based

1.45 16.68 18.13

Residential care 0.62 19.48 20.10Total 16.58 225.85 242.42Note: (a) A client may have received more than one service thus there may be double counting across categories.Source: ONS (2008a), ONS (2008b) and Access Economics calculations.

Table 3-27: Estimated Expenditure On Community Services For Those With Sight Loss, Devolved Nations 2008

Table 3-27 Partial sight and blindness

18-64

Partial sight and blindness

≥65

Dual sensory

loss18-64

Dual sensory

loss≥65

Total

Region £ million £ million £ million £ million £ millionScotlandCommunity-based

1.72 16.38 0.22 2.58 20.90

Residential care

0.25 13.15 0.09 3.01 16.50

Total - Scotland

1.97 29.53 0.31 5.59 37.40

WalesCommunity-based

0.73 5.69 0.07 0.91 7.40

Residential care

0.10 4.57 0.03 1.06 5.76

Total - Wales

0.83 10.26 0.10 1.97 13.16

Northern IrelandCommunity-based

0.54 5.12 0.07 0.81 6.55

Residential care

0.08 4.10 0.03 0.95 5.16

Total – Northern Ireland

0.62 9.22 0.10 1.76 11.71

Source: National Statistics (2008), DHSSPS (2008), WAG (2008b) and Access Economics calculations.

3.8 Capital And AdministrationWithin the Department of Health there is a significant proportion of expenditure undertaken on administrative functions and capital purchasing. This cost is across all program budgeting areas and the data is not broken down into specific areas. Total administration expenditure by the Department of Health was around £234.0 million in 2006-07 while capital spending was around £3.3 billion (DoH, 2008).

The proportion of these costs attributable to eye conditions leading to partial sight and blindness was estimated by assuming the level of administrative and capital expenditure attributable to eye conditions is in proportion to the level of gross operating costs across program budgeting areas. Gross operating cost for the entire NHS England was approximately £84.2 billion in 2006-07 (DoH, 2008a). Of this, around £1.4 billion (or 1.6 per cent) was spent on ‘Problems with vision’. Multiplying this proportion by total administrative and capital costs, it is estimated that administrative costs and capital costs attributable to eye conditions leading to partial sight and blindness is around £3.8 million and £54.4 million respectively in 2008.

3.9 Summary Of Health Care System ExpenditureThe estimated total health care system expenditure was calculated as £2,145 million for 2008. A summary of health care system expenditure by expenditure type and country is shown in Table 3-28. A summary of health care system expenditure by condition is shown in Table 3-29. As not all health care system expenditure could be split by country or condition these have been left as ‘n.a.’ within the tables.

Table 3-28 Summary Of Health Care System Expenditure, By Country 2008

Table 3-28 England£ million

Scotland£ million

Wales£ million

N.I.£ million

Total£ million

Hospital recurrent expenditure

490.69 57.10 31.59 13.34 592.74

Non-admitted expenditure

437.46 31.68 26.77 12.08 507.99

Prescribing expenditure

134.90 10.78 9.37 3.09 158.12

General ophthalmic services (GOS)

386.28 56.93 24.44 16.39 484.04

Expenditure associated with injurious falls

n.a. n.a. n.a. n.a. 25.10

Research and development

n.a. n.a. n.a. n.a. 13.99

Residential care and community care services

242.42 37.40 13.16 11.71 304.69

Capital and administration

n.a. n.a. n.a. n.a. 58.22

Total 2,144.89Note: Cells that could not be split due to lack of information are labelled n.a.

Table 3-29: Summary Of Health Care System Expenditure, By Condition 2008

Table 3-29 AMD£m

Cataract£m

DR£m

GLCMA£m

RE£m

Other£m

Total£m


37.99 334.66 78.63 14.60 13.81 113.05 592.74


15.56 82.48 245.34 19.75 55.13 89.75 507.99


3.42 29.29 5.21 109.66 0.77 9.79 158.12


7.93 23.98 11.16 11.52 424.75 4.70 484.04


n.a. n.a. n.a. n.a. n.a. n.a. 25.10


3.42 0.73 3.32 1.04 5.49 0.00 13.99


n.a. n.a. n.a. n.a. n.a. n.a. 304.69


n.a. n.a. n.a. n.a. n.a. n.a. 58.22

Total 2,144.89Note: Cells that could not be split due to lack of information are labelled n.a.

4. Indirect CostsThis chapter investigates indirect costs that are related to partial sight and blindness. As they do not relate to the direct health care system costs, these costs are indirectly associated with sight loss rather than costs associated with treatment. Unfortunately there was not enough data to adequately split indirect costs by condition so this chapter presents totals for partial sight and blindness. Indirect costs examined within this chapter include: productivity losses from reduced labour market participation through lower

employment, greater absenteeism, and premature mortality associated with partial sight and blindness;

costs to informal carers from providing care to someone with partial sight and blindness;

partial sight and blindness devices and modifications, such as the cost of low vision services, mobility and communication devices, visual aids, and modifications to homes; and

deadweight loss associated with raising additional tax revenue to publicly fund health care services and direct payments to people with partial sight and blindness.

In evaluating indirect costs, it is important to make the economic distinction between real costs and transfer payments. A real cost is incurred when economic resources are used in the production of goods and services, such as land, labour and capital. Using resources in one area of the economy reduces the opportunity to produce goods and services in other areas of the economy. Transfer payments are defined as payments from one economic agent to another that are made without receiving any good or service in return. Rather than payments made for the use of any good or service, they are a transfer of claims over real resources. Some examples of transfer payments in include taxes, subsidies, and pensions. As transfer payments do not represent a real economic cost they have not been presented as an economic cost within this report. However, they have been estimated to calculate the associated deadweight loss to the economy.

4.1 Productivity LossesSight loss can have an impact on economic productivity through three primary channels. These comprise: reduced productivity per worker due to the impacts of sight loss on the

ability to undertake work; temporary reduction in the size of the labour force (total number of hours

worked) due to absenteeism associated with partial sight and blindness; and

permanent reduction in the size of the labour force due to premature retirement and premature mortality within working age due to partial sight and blindness. (Within this study it was assumed that working age is between 18 and 64 (inclusive) for males and 18 to 59 for females (inclusive))

As total labour productivity is typically lower for people with partial sight and blindness, the loss in productivity represents a real cost to the UK economy.

However, a loss in productivity of an individual due to sight loss will only equate to a loss in productivity to the economy under fairly strict conditions. These are: the economy is at full employment so any reduction in hours worked due

to sight loss, or any permanent reduction in labour force participation through early retirement or death, cannot be replaced by employing or increasing hours of other workers; and

the income of an individual is proportional to the total value added to production.

The first condition will fluctuate over time as the economy moves into, and out of, full employment. A reduction in labour when labour is scarce will have a greater impact on productivity compared to an economy with an abundant labour supply. Although the UK economy is currently close to full employment it is problematic to determine the scarcity of labour into the future. Given demographic ageing and current immigration and workforce policy, it is reasonable to assume that the long term goal of government is to keep the economy at full employment. This means a temporary or permanent reduction in working hours due to partial sight and blindness cannot be replaced by another worker. Consequently a loss in productivity due to sight loss is expected to represent a real cost to the UK economy.

The second condition (income of an individual is proportional to the total value added to production) will occur if there is a perfect labour market such that the marginal benefit from an additional hour of work (the value added) is equal to the marginal cost (the wage). In reality, the labour market is far from perfect for a number of reasons, for example asymmetric information within the market and labour market restrictions imposed by government regulation and natural labour market barriers. In addition, synergy created between labour, capital and land means a reduction in working hours may also impact the productivity of other factors of production. Consequently the value of productivity from labour will be larger than the wage provided to an individual so using lost income from partial sight and blindness as a proxy for lost productivity will tend to underestimate the true cost.

It is likely that in the absence of sight loss, people with sight loss would participate in the labor force and obtain employment at the same rate as other people in the UK and earn the same average weekly earnings. The implicit assumption is that the numbers of such people would not be of sufficient magnitude to substantially influence the overall clearing of the UK labor market so that the average wage would remain the same.

4.1.1 Lower EmploymentThe cost of unemployment due to partial sight and blindness can be calculated using either a frictional approach or a human capital approach. The frictional approach only includes the search and hiring cost (a bring forward) and productivity loss till the worker is replaced. However the human capital approach includes the search and hiring cost (a bring forward) and productivity loss of the worker’s contribution relative to what it would have been in the absence of the condition (ie, this could amount to total earnings for the rest of life expectancy if the worker dies or is permanently disabled and unable to return to work). A human capital approach is appropriate for industrialised countries in which there is near-full employment. This is because the removal of labour constrains growth in the long run production possibilities frontier, ceteris paribus. A frictional approach is appropriate for developing countries where typically there is a large unemployment pool and/or underemployment.

A number of studies have estimated the cost of unemployment due to sight loss in the UK using the human capital approach. For example, a study by Ethical Strategies (2003) estimated the cost of loss productivity across five hypothetical individuals with sight loss. The study concluded that productivity losses are primary cost drivers in the total cost of sight loss. For example, productivity loss accounts for around 61 per cent of lifetime costs associated with congenital sight loss in adolescence.

Lafuma et al (2006) estimated the loss of income for people with sight loss in the UK at around €3.4 billion in 2004. They concluded that sight loss has a significant impact on productivity, equating to around 22.5 per cent of the total non-medical costs associated with sight loss in the UK.

RNIB has also estimated the cost of productivity loss due to sight loss (RNIB, 2004). Using the 2001 Labour Force Survey, the study noted that around 136,000 people of working age in the UK reported they were disabled due to ‘difficult seeing’. Comparing employment rates of those not disabled to the employment rates of those with ‘difficult seeing’, the study estimated that there was approximately 52,650 less people in employment due to sight loss

in 2001. Multiplying this ‘employment gap’ by average annual earnings for 2001, this equated to a loss in productivity of around £1.08 billion (RNIB, 2004).

Productivity loss due to sight loss will depend on the age of the person when sight loss first occurs. Generally the younger the person, the greater the impact sight loss will have on productivity. Those with sight loss have a lower participation rate in paid workforce activities (Ethical Strategies 2003; RNIB 2004; Lafuma et al 2006). This is the traditional measure of a loss in productivity from sight loss.

To estimate the loss in productivity, this study used a report prepared by the Institute for Employment Studies on the labour market experiences of people with seeing difficulties (IES, 2008). Their report used data from the UK Labour Force Survey, taking combined data from 12 quarters over the period July 2004 to June 2007. The survey asked a question on whether a person has a health problem or disability that is expected to last for more than a year, and distinguishes these problems by asking what kind of health problem or disability, of which one category is ‘difficulty in seeing’. From these definitions the survey picks up the difference between those with sight loss and those without.

Table 4-1 presents different employment rates between those with sight loss and those without, as presented within IES (2008). Those with no disability or seeing difficulty of the working age population had an employment rate of 80.3 per cent, whilst those with a ‘seeing difficulty’ had an employment rate of 62.2 per cent, revealing a gap of 18.1 per cent. Multiplying the employment gap by the amount of people with a seeing difficulty, there are approximately 33,260 less people in employment due to sight loss. The employment rate gap extends even further for those who are long-term disabled with a seeing difficulty, with the gap growing to 32.6 per cent. (The IES (2008) data represents an average rate of employment and is not disaggregated by age or gender. Therefore this estimate does not take account that females have lower wage levels than males, differing prevalence rates and employment rates. In addition, the LFS survey looked at the working age population only (16 – 64(M)/59(F) years old), so the lost productivity from the retirement age group could not be taken into account.)

Other studies have provided lower employment rates for those with seeing difficulties. A previous RNIB report used slightly lower employment rates from 2001, with those disabled with a seeing difficulty having an employment rate of only 44.3 per cent (RNIB, 2004). A separate study for RNIB reported even lower employment rates for those blind or partially sighted (visual acuity of

less than 6/18) of 27 per cent, while those with better visual acuity from 6/18 to 6/12 had an employment rate of 39 per cent (Bruce and Baker, 2002). Similar figures were produced for Great Britain in a Network 1000 (2006) report, which estimated employment rates to be 34 per cent for those registered blind or partially sighted. This lower estimate of employment rates may be explained by the fact that the study focused on those with more significant sight loss who are less likely to work.

Table 4-1: Employment Rates, By Level Of Seeing Difficulty 2007

Working Age Population Employment rate (%)All 74.6Not disabled and without seeing difficulty

80.3

Seeing difficulty 62.2Long-term disabled with seeing difficulty

47.7

Not disabled with seeing difficulty 82.8Source: IES (2008)

To calculate the loss in productivity, employment rates by age group derived from ONS (2007b) were multiplied by the prevalence of those within working age that had sight loss. This provided an estimate of the number of people with sight loss that would have been employed if their sight loss could be corrected. The number of people with sight loss that were employed was estimated by multiplying the number of people with partial sight and blindness by the rate of employment adjusted by the employment gap derived from IES (2008). (There is evidence that the gap between employment rates becomes more pronounced as the level of visual acuity becomes worse. As employment rates across the definitions of partial sight and blindness used within this study are not available this study has used the average gap across all levels of visual acuity.) The difference between these two calculations represented the number of people that are not employed due to their sight loss. This was multiplied by the median gross weekly earnings derived from ONS (2007a) to estimate the total cost of productivity loss due to lower employment amongst those with sight loss. The employment gap and the average weekly earnings are shown in Table 4-2. The employment gap and the productivity loss associated with this gap is shown in Table 4-3, which shows the loss in productivity is estimated to be around £1.63 billion in 2008.

Table 4-2: Employment Gap And Median Gross Income For Those With Sight Loss 2008

Employment gap Male Female AllAge % % %18-24 16.5 14.9 15.725-34 21.5 17.6 19.535-49 21.5 18.3 19.950-64 (M), 50 – 59(F) 17.5 16.7 17.2

Median gross income Male Female AllAge £/week £/week £/week18-24 351.10 325.20 337.7425-34 488.01 431.86 463.5135-49 583.61 448.87 531.9550-64 (M), 50 – 59(F) 552.91 410.36 496.35Source: Access Economics calculations.

Table 4-3: Productivity Loss Due To Partial Sight And Blindness 2008

Employment gap Male Female AllAge No No No18-24 1755 1404 315225-34 3273 2368 560435-49 11053 10435 2156650-64 (M), 50 – 59(F) 20643 12076 32662Total 36,724 26,283 62,984

Productivity Loss Male Female AllAge £million £million £million18-24 32.14 23.81 55.9425-34 83.29 53.33 136.6335-49 336.35 244.23 580.5750-64 (M), 50 – 59(F) 595.15 258.40 853.55Total 1,046.93 579.77 1,626.70Source: Access Economics calculations.

4.1.2 AbsenteeismIn addition to workforce separation, people with partial sight or blindness may be absent from work more often as a result of their sight loss. For example, the higher level of risk associated with falls, accidents, and depression means there is a greater probability that a person with sight loss will take time off work.

There are no UK studies that have formally evaluated the number of additional days a person with sight loss is absent from work compared to a person without sight loss. Using data from the United States and simple linear regression to control for the impact gender, age, and income on the average number of days off work per year, Access Economics (2006) estimated that those with sight loss are likely to have an additional 4.1 days off work per year on average. As the data was not rich enough to specifically account for co-morbidities the number of days off may be an over estimate, although some of the impact from co-morbidities would have been picked up in the income variable.

For all those with sight loss and employed (using the employment data by age and gender from Section 4.1.1), the absenteeism loss was estimated as the total number of employed with partial sight and blindness multiplied by the average additional days off work for someone who has sight loss. Multiplying this by the median daily wage rate for each age bracket and gender (The median daily wage rate for males and females within each age bracket was calculated by dividing the median gross weekly earnings from Table 4-2 by the number of work days in a week) provided a total loss of productivity estimate of £79.8 million due to absenteeism in 2008. A breakdown of this total by age and gender is shown in Table 4-4.

Table 4-4: Productivity Loss Due To Absent Days Resulting From Partial Sight And Blindness 2008Days off work Male Female AllAge (000s) (000s) (000s)18-24 22.47 17.97 40.3025-34 41.89 30.31 71.7835-49 141.46 133.55 276.2350-64 (M), 50-59(F) 264.20 154.56 416.07Total 470.01 336.38 804.37

Productivity loss 1. Male 2. Female 3. AllAge (£ million) (£ million) (£ million)18-24 1.58 1.17 2.7525-34 4.09 2.62 6.7135-49 16.51 11.99 28.5050-64 (M), 50-59(F) 29.22 12.69 41.90Total 51.39 28.46 79.85Source: Access Economics calculations.

4.1.3 Premature MortalityProductivity losses associated with partial sight and blindness also arise from premature mortality through accidents, depression and other sources (for example, motor vehicle accidents).

In estimating increased risk of mortality, it is important to control for the age and gender of a person with sight loss (Globe et al, 2005; Anstey et al, 2001). For example, Klein et al (1995) reported that people with specific vision conditions had decreased survival chances (increased mortality risk) of 1.57 for the presence of sight loss and of 1.28 for any cataract. However, once cardiovascular disease was taken into account none of the conditions causing sight loss showed a statistically significant odds ratio for decreased survival.

An improved level of statistical control was achieved in the Melbourne Visual Impairment Project (MVIP) where partial sight and blindness was found to be significantly associated with increased risk of mortality of around 2.34 times (McCarty et al, 2001). The result took into account the confounding presence of age and age-related comorbidities, such as basic cardiac risk factors.

Wang et al (2001) report a 70 per cent increased chance of mortality with the presence of any sight loss. Their analysis took into account comorbidities such as a history of significant events (cancer, stroke, gout and diabetes), some of which result from basic cardiovascular risk factors such as hyperlipidemia and hypertension.

The mortality rate of people with sight loss in the UK has been estimated within Mortality Statistics 2005, a report produced by the ONS (ONS, 2005). This report presents deaths occurring in England and Wales, classified by sex and age and by other selected information collected at the time of registration, such as method of certification and place of death. Death rates per million population by underlying causes are classified by ICD-10 and specifically lists diseases of the eye and adnexa by 10 year age cohorts and gender. Death rates are based on details collected when deaths are certified and registered, which are mostly undertaken by a medical practitioner using the Medical Certificate of Cause of Death (MCCD).

However data within Mortality Statistics 2005 for diseases of the eye and adnexa is scarce. For example, death rates are only supplied for males between ages 15 to 24, 45 to 54, and 65 and over, while death rates for females are only supplied for ages 75 and over. Furthermore, it is questionable whether death rates attributable to sight loss would be adequately captured within the MCCD. For example, a person that dies from

a fractured skull due to an accident related to sight loss would have their cause of death recorded as a head injury rather than sight loss.

To estimate the mortality rate of adults with sight loss in the UK, the mortality rate of the general population (sourced from ONS, 2005) was multiplied by an odds ratio of 2.34, which was derived from the MVIP (McCarty et al, 2001). Deaths due to sight loss were calculated by multiplying the estimated number of deaths of people with sight loss by an attributable (etiological) fraction of 0.83 per cent. This fraction was derived from Access Economics (2004) and is based on the MVIP data.

The productivity loss from those who die prematurely was estimated based on the assumption that if they had lived, the person would have earned an average annual income up until their retirement. (Data suggests there are no significant income differences between people with partial sight and blindness and people without (IES, 2008)) Average incomes were calculated as £24,857 for males and £20,305 for females (derived from Table 4-2). Retirement age was represented by the State Pension age, which is 65 for males and 60 for females. (http://www.thepensionservice.gov.uk/state-pension/home.asp, accessed 13 November 2008) The number of people who were in employment at the time of their death was calculated by multiplying the number of deaths due to sight loss by the employment rate of those with sight loss, which was 62.2 per cent (IES, 2008). The present value of lost earnings was calculated using a discount rate of 3 per cent over the number of years until retirement. Table 4-5 shows that the estimated total present value loss of productivity associated with premature mortality is around £2.38 million in 2008.

http://www.thepensionservice.gov.uk/state-pension/home.asp

http://www.thepensionservice.gov.uk/state-pension/home.asp

Table 4-5: Cost Of Premature Mortality From Partial Sight And Blindness 2008

Table 4-5

No, of people with sight loss of working age

Deaths per 1,000 people due to sight loss

Deaths of people due to sight loss

No. employed

Years to retirement

Present value of lost earnings per person £

Total£ million

Male18-39 26,037 0.02 0.47 0.28 35 309,176 0.0840-49 43,677 0.05 2.19 1.36 20 275,150 0.3750-54 26,804 0.07 1.90 1.18 13.5 225,150 0.2755-59 35,710 0.17 6.25 3.89 8.5 164,340 0.6460-64 55,654 0.17 9.74 6.06 3.5 78,447 0.48Female18-39 23,309 0.01 0.25 0.14 30 250,953 0.0340-49 50,221 0.03 1.63 1.01 15 195,489 0.2050-54 30,840 0.05 1.45 0.90 8.5 134,243 0.1255-59 41,399 0.11 4.56 2.83 3.5 64,081 0.19Total 330,050 n.a. 28.39 17.66 n.a. n.a. 2.38Source: Access Economics calculations.

4.2 Informal Care CostsInformal care is the provision of home care to another person without receiving pay (although some informal carers in the UK may receive a government allowance based on an evaluation). Most commonly informal care is the provision of care by a family member, friend, neighbour or community member.

The level of informal care associated with sight loss depends on whether the person is able to live independently while maintaining an appropriate quality of life. Using UK data, Stevenson et al (2004) showed that the ability for a person with sight loss to care for themselves is adversely influenced by sight loss. In a study of individuals with AMD recruited through a hospital eye clinic in Northern Ireland, Ke et al (2007) found that the level of formal and informal care services utilised by an individual depends on the level of visual acuity in the better eye, the age of the individual, and the level of access to informal care, for example, whether the person lives alone or not. International studies have also found a positive relationship between the level of informal care and

the prevalence of partial sight and blindness (Wang et al 1999, Schmier et al 2006).

RNIB (2004) estimated that the cost of informal care for the blind and partially sighted was around £1.5 billion using studies undertaken by Carers UK, ONS, DoH Survey of Carers, Adults Needs Survey and RNIB’s own survey. This was based on the assumption that each person with sight loss over the age of 60 received one hour of care per day associated with their sight loss.

In order to estimate the total cost of informal care, the time spent providing care to people with sight loss is required along with a monetary figure representing the value of informal care. It is difficult to separate the level of informal care provided due to partial sight and blindness when the person receiving care has comorbidities that also require informal care. For example, a person may receive informal care for dementia and sight loss at the same time.

However, there are further significant costs in addition to the value of lost time in providing informal care. For example, in an evaluation of informal care in the UK, Carmichael and Charles (2003) noted that informal carers also forgo significant earnings because they have less opportunity to undertake higher paid employment and therefore earn less than equally qualified non-carers. This is because informal carers require more flexible working arrangements, which make them less likely to be promoted.

In terms of estimating a monetary value of informal care provided to people with partial sight and blindness, two methodologies can be used – the replacement cost method and the opportunity cost method. (There is a third methodology known as the self-valuation method but this is seldom used due to the inherent bias associated with the value people place on the services they provide.)

The replacement cost method measures the cost of substituting informal care for formal care services. That is, it values the output of production (van den Berg et al 2006). Thus, the number of hours providing informal care to people with sight loss is multiplied by the cost of providing care from the formal care sector (which is deemed a close substitute).

The cost of providing care in the formal sector will depend on the level of sight loss and any co-morbidities the person may have as greater demands are placed on carers as a person’s level of disability increases. However, the replacement cost method may overestimate the value of informal care as it assumes the person receiving care, or society, is willing to pay for the

services typically provided by a family or friend. Due to budget constraints faced by individuals and community service funders this may not be the case. Furthermore, the replacement cost method does not take into consideration any differences in the quality of care and will therefore overestimate the value of informal care if formal care is of a higher quality. Also, the time spent on providing formal care may be different to the time foregone by an informal carer if a formal carer is more efficient. If this is the case it would also lead to an overestimation of the value of informal care. Finally, if the informal carer receives utility from providing care, then the replacement cost method could actually underestimate the value of informal care.

The opportunity cost method measures the value in alternative use of time spent caring, which is typically valued by productivity losses (or value of leisure time) associated with caring. This is based on the assumption that time spent providing informal care could be alternatively used within the paid workforce or in leisure activities. The value of informal care using the opportunity cost method can be represented by:

Value of informal care = tiwi

where ti is the time provided by individual i on providing care and w i is the net market wage rate of individual i (van den Berg et al 2006). For those who provide informal care but are not in paid work (for example, children or those who have retired) the value of providing informal care is the value of the lost opportunity of undertaking leisure time. This can be approximated by the willingness to pay to undertake leisure, or to avoid work. However, the value of leisure time is often proxied by an average age and sex specific wage rate (Brouwer and Koopmanschap 2000; Heitmueller 2007). If the value of non-work is more (less) than the average wage rate, the opportunity cost method will under (over) estimate the value of informal care.

The replacement cost method and the opportunity cost method differ conceptually. The former values outputs while the latter values inputs. From a theoretical perspective, the opportunity cost method is the benchmark (van den Berg et al 2006).

Within this study, a tops-down approach using the 2001 Census was used to determine the number of informal care hours provided to people with sight loss, and an opportunity cost methodology (in line with Access Economics 2008a, 2008b, 2006) was used to value these hours.

The decennial UK Census 2001 (ONS, 2003) collected data on the number of informal carers in England and Wales. Similar data for Scotland (GROS,

2003) and Northern Ireland (NISRA, 2003) was also collected for the same period. Data was recorded according to informal carer age, sex and the number of hours care provided each week.

Approximately 5.9 million people were recorded as providing some level of informal care to another person in the UK as at April 2001. Table 4-2 shows an estimate of the number of people providing informal care in the UK in 2007. These were calculated by multiplying the proportion of informal carers in 2001 derived from the Census by the population for 2007 (from Section 2.1). Although this accounts for the population growth in the UK it does not adjust for any change in the proportion of informal carers since 2001. Consequently Table 4-6 may underestimate the total number of the carers considering there has been a rise in the number of carers since the last UK Census (Carers UK, 2007).

Table 4-6: Number Of Informal Carers In The UK By Age, Sex And Hours Spent Providing Care, 2006-07

Age Male1-19 hrs

Male20-49 hrs

Male≥50 hrs

Male1-19 hrs

Male20-49 hrs

Male≥50 hrs

5-15 46,275 4,291 4,092 52,896 5,176 4,80316-64 1,443,620 208,578 316,676 1,974,416 335,189 567,47765 268,895 57,829 187,133 289,943 58,769 206,404

Total 1,758,790 270,698 507,901 2,264,359 399,134 778,684Source: ONS (2003), GROS (2003), NISRA (2003) and Access Economics calculations.

To calculate the total number of hours of informal care, the same methodology used by the University of Leeds in valuing informal carers for Carers UK was used (Carers UK, 2007). Within their methodology it was assumed that the average amount of care for those providing ?50 hours of care per week was 50 hours. For those providing between 20 to 49 hours of care the average amount of care was assumed to be 35 hours of care. For those providing between 1 to 19 hours of care per week it was assumed that 31 per cent provided 15 hours of care, 31 per cent provided 7 hours of care, and 38 per cent provided 2 hours of care.

The total number of hours of informal care represents a total across all people receiving informal care for all conditions (for example, it includes care provided to those with dementia). To calculate an estimate of total informal care associated with partial sight and blindness, the proportion of activity for physically disabled adults and older people aged 65 and over experiencing

sight loss and dual sensory loss for community-based and residential services in England was used (this was shown to be 3.0 per cent in Section 3.7). Although this proportion relates to formal care services it was assumed that the level of informal care used for partial sight and blindness is in proportion to the level of formal care used for partial sight and blindness. This may be the case if the level of formal and informal care is in proportion to the burden of disease. Total number of hours of informal care is shown in Table 4-7.

Table 4-7: Number of Informal Carers In The UK Providing Care To Those With Partial Sight And Blindness, 2008

MalesAge

2hrs 7hrs 15hrs 35hrs 50hrs

5-15 1.1 3.0 6.5 4.5 6.116-64 32.9 94.0 201.4 219.0 475.0≥65 6.1 17.5 37.5 60.7 280.7Total 40.1 114.5 245.4 284.2 761.9

FemalesAge

2hrs 7hrs 15hrs 35hrs 50hrs

5-15 1.2 3.4 7.4 5.4 7.216-64 45.0 128.5 275.4 351.9 851.2≥65 6.6 18.9 40.4 61.7 309.6Total 52.8 150.9 323.3 419.1 1,168.0Source: Carers UK (2007) and Access Economics calculations.

To estimate the cost of informal care related to partial sight and blindness, the estimated total number of informal care hours was multiplied by the average per hour wage rate for males and females, which was £12.30 and £10.05 respectively. (This was derived from the median weekly wage shown in Table 4-2 and 37.5 hours of work per week.) These costs of informal care are slightly less than findings by the Scottish Executive Central Research Unit in 2001 and 2002, who estimated the hourly market value of informal care to range from £7.50 to £9.24 (£16.07 to £19.80 in 2008 prices) (Heitmueller and Inglis 2007).

This provided an estimate of £2,029.7 million for the cost of informal care relating to partial sight and blindness in 2008.

4.3 Devices and ModificationsAdults who have sight loss require a variety of devices, special equipment and home modifications to function adequately and to enhance their quality of life. Some of these include: alternative format materials, for example large print or Braille publications,

labels and tags, locator dots; mobility devices, for example canes, guide dogs, torches; glasses, sunglasses (glare reducing); low vision devices, for example magnifiers, telescopes and closed circuit

TVs (CCTVs); computer devices, for example computer speech technology, large print or

Braille display; daily living devices such as clocks and watches, coin sorters, bathroom

and kitchen accessories (for example, liquid level indicators, needle-threaders), sport and recreation items (for example, embossed dice or playing cards, ringing balls);

recording and playback devices; talking appliances such as calculators, scales, thermometers; educational devices for visual, audio or tactile learning; and enhanced lighting, grab rails, ramps.

The most common types of technical aids for adults included mobility and communication devices (such as guide dogs, white sticks, wheelchairs, and tape recorders), optical aids and home modifications (Lafuma et al, 2006).

The majority of studies that have sought to estimate the cost of devices and modifications have focused on adults. (According to Dr J. Ravenscroft (pers. comm.. December 2008) the cost of devices and modifications is greater for children. This is because children often need low vision devices at home and school, and devices tend to change as the child grows older (for example, the more mobile a child becomes the more portable each device needs to be). Furthermore, children are more likely to damage low vision aids and devices.) In a cross-sectional study across 4 countries, it has been estimated that 2 per cent to 10 per cent of blind people declared guide dogs as a necessity (Lafuma et al, 2006). In the UK, the cost to the person with sight loss is minimal, with the Guide Dogs for the Blind Association (GDBA) charging a nominal 50p. However a substantial amount is expended by the GDBA, with a total of around £62.3 million spent in 2007 (GDBA, 2007). This included costs of generating voluntary income (£12.8 million), governance costs (£1.3 million) and charitable expenditure (£48.2 million). The greatest component of this expenditure was on the provision of guide dogs, which totalled around

£41.1 million and enabled 690 people to be trained and qualified with a guide dog.

Expenditure for the GDBA is funded through income received from community fundraising, donor based funding, raffles and draws, corporate and trust income, legacies, donated services and facilities, and gifts in kind. Assuming a ten year life span, dogs cost around £9,024 a year to fund a guide dog partnership over the life of the partnership. This was calculated by dividing the total expenditure of GDBA in 2007 by the number of people and dogs trained. At the end of 2007 there were 4,466 guide dog owners in the UK, giving a total cost of around £40.3 million for 2007.

Lafuma et al has estimated the cost of communication devices, including a tape recorder (unit cost of £36, and resource use of 4.3 per cent above those without sight loss), a computer interface (unit cost of £2839, and resource use of 6.1 per cent) and software adapted for blindness (unit cost of £1,727, and resource use of 5.9 per cent).

Low vision aids, particularly simple devices such as a magnifying glass, are an effective means of improving reading ability in people with sight loss, with almost nine out of 10 consumers having an improved ability to read (Margrain 2000). The most recent study estimated total optical assistance to have a unit cost of £4,357, and with a resource use of 18.3 per cent (Lafuma et al 2006). In terms of utilisation, Margrain (2000) estimated that the most common type of magnifier was an illuminated stand magnifier (30 per cent), followed by an illuminated hand magnifier (20 per cent), hand magnifier (20 per cent), a high power reading addition (13 per cent) and a stand magnifier (6 per cent).

Cruess et al (2008) assessed the costs of different types of magnifying glasses, and estimated the cost of a magnifying glass (£47), stand magnifier (£37), electronic magnifier (£1,950), filter (£40), telescope (£210), and a closed-circuit television system (£2,200) using 2005 values. In estimating the cost of low vision aids, Bonastre et al (2002) used a simple measure of low vision aids, an estimate that magnifying glasses cost €50 over a one year period, and that low vision aids were used by 90 per cent of people with sight loss. However the estimate for the closed-circuit television system was between £362 and £604 per year, much smaller than Cruess et al (2008).

Landers et al (1999) formed estimates of low vision aids costs based on the hospital eye service prescription forms from a district general hospital with a Low Vision Aid Service. Two audits were conducted, the first being a retrospective analysis of the forms to outside optometrists/opticians between 1990 and 1992, whilst the second audited the costs of using the ‘in-house’

NHS low vision aid service. It found that the average low visual aids cost per patient was £136.33 from the first audit, and £56.41 for the second (inflated to 2000 figures). The most common low vision aids prescribed were a magnifying glass, telescopes, typoscopes and ultraviolet shields. Meads and Hyde (2003) comment that only 32 per cent of low vision aids are obtained through the ‘in house’ service, and therefore, the higher cost estimate should be preferred.

Modifications to the home may include enhanced lighting, installing grab rails, ramps for those who require wheelchairs. Lafuma et al (2008) estimated modifications to the home to be around £79.31 (2004 values). Building adaptations were carried out less frequently for people with sight loss living at home than for those institutions. Home adaptations included adaptations made to toilets, the kitchen, bathroom, tables, seats, beds, ramps, door-opening devices and stair-lift.

In developing a health technology appraisal for the National Institute for Clinical Excellence (NICE), Meads and Hyde (2003) estimated the costs averted by the UK government in preventing people becoming blind. Using a literature review, they estimated that the cost of blind registration was £59.70, the cost of low vision aids was £136.33, and the cost of low vision rehabilitation was £205.30 (in 2002 prices).

Smith et al (2004) has also estimated the cost of blindness from a government perspective suggesting a one-off cost of £159 (in 2000 prices), ranging between £50 and £300. These estimates included blindness registration, low vision aids and rehabilitation services. Cruess et al (2008) concentrated on the costs of bilateral neovascular AMD and estimated that the total annual vision related equipment costs per patient amounted to £270.69. Their definition of vision related equipment included glasses and spectacles in addition to the devices of magnifiers, filters, telescopes and closed circuit television.

Using two cross sectional handicap, incapacity, and dependency (HID) surveys of partial sight and blindness in France, Lafuma et al (2006) estimated that the average annual cost for all devices was £394.73 per year in the general community for those with self reported low vision and blindness (in 2004 prices). This estimate included the cost of sticks, white sticks, walking aids, wheelchairs, guide dogs, optical assistance, computer interface, software adapted for blindness and tape recorders. In addition, Lafuma et al (2006) estimated that the cost of home modifications was £79.31 per year on average (in 2004 prices). These estimates were based on cost information and data on assistance requirements, home adaptations and allowances

within France. The study assumed that demand and supply of these items would be similar (and therefore the prices) across France and the UK.

4.3.1 Cost of Devices and ModificationsThe preferred methodology in estimating the total costs of devices and modifications is to multiply annual unit costs by the annual utilisation rates of devices. Although annual unit costs are available (as presented in Section 4.3), utilisation data was not available.

Instead the total annual cost of devices and modifications has been calculated by multiplying the average cost of devices and modifications presented in Lafuma et al (2006) by the prevalence of moderate and sever sight loss in the UK for the adult population. (It is unlikely that those with mild sight loss and blindness would utilise most items included within the average cost presented by Lafuma et al (2006). Consequently these people were left out to ensure a conservative estimate was made.) As Lafuma et al presented estimates in 2004 prices these were adjusted to 2008 prices using an average UK inflation rate over that period of 2.01 per cent (Statistics UK, 2008a). (As Lafuma et al (2006) presents average prices in Eurodollars, they were first converted back into Sterling by using the exchange rate used within their study (£1 = €1.5).) This gave an average total per person cost for devices and modifications of £515.13 per year. The total cost of devices and modifications was estimated as £336.5 million for 2008.

4.4 Deadweight Loss Public funding of direct health care system costs and community services related to partial sight and blindness means that the UK government must increase tax revenue to achieve a budget neutral position (This implicitly assumes funds have not been directed from some other area of the health care system.). Consequently tax rates such as income tax rates and Value Added Tax (VAT) must be higher that they would have otherwise been.

As noted previously, tax and subsidy revenue is not an economic cost but a transfer of payments from one individual to another. It has therefore not been included in this study. However, increasing tax revenue is not frictionless as tax reduces the efficiency with which the economy’s resources are used. For example, an increase in income tax rates will increase the relative price of work compared to leisure and therefore create a disincentive to work. Alternatively an increase in VAT increases the price of goods and services results in a loss in sales. Consequently there is an associated reduction in consumer and producer surplus, which is known as the deadweight loss, or excess burden, of tax.

While the costs associated with deadweight loss will depend on the method used to raise additional taxes, (In general it is more efficient to place taxes on markets that are relatively inelastic.) the social cost will not be zero and should therefore be included as a cost of partial sight and blindness. The usual assumption in program evaluation is to assume that additional taxes are raised through income tax rate changes, and this is what has been assumed in this study.

Seminal studies that have evaluated the marginal welfare cost of raising additional tax revenue (known as the marginal cost of public funds (MCF)) mostly relate to the United States (Browning 1976, Stuart 1984, Ballard 1985, Browning 1987). Estimates have ranged from zero marginal cost to well over 100 per cent. This wide range has been due to alternative models used (partial versus general equilibrium), alternative parameter estimates, and assumptions on the adjustment of employment relative to changes in tax rates (labour supply elasticities).

There are limited studies that have specifically focused on the UK labour market. However, Kleven and Kreiner (2006) provide estimates of the MCF for five European countries using micro data on taxes, benefits paid, and labour supply elasticities across different income levels. Within this study, nine estimates of the MCF were provided for the UK, ranging from 0.93 to 1.36 (where 1 represents zero MCF) and based on alternative scenarios regarding alternative income elasticity scenarios. For the purposes of this study we have used the simple average of the MCF across the nine scenarios, calculated as 1.12. Consequently for every additional £1 raised by the UK government to fund costs associated with partial sight and blindness it has been assumed there is £0.12 in lost welfare due to deadweight loss.

In order to calculate the deadweight loss associated with partial sight and blindness, the additional revenue raised by the UK government to fund public health care system costs, residential and community care, aids and equipment, and direct payments to those with partial sight and blindness and their carers must be estimated. The cost associated with public funding of the health care system, residential and community care was derived from Chapter 3. The costs associated with aids and equipment was derived from Section 4.3.

To determine the costs associated with direct payments, a review of the current payments available to people with sight loss and carers was undertaken using data from the Department for Work and Pensions (DWP, 2008). This is a comprehensive dataset on the number of people receiving

direct payments and the average weekly rate of benefit within Great Britain, by condition including eye and adnexa. As the data does not include Northern Ireland this was supplemented with payment volume data collected from the Department of Social Development (DSD, 2008). (As this data was not presented in the same format as the data from DWP (2008), proportional splits across rates from the DWP (2008) were applied to the total direct payments from the DSD (2008).)

The main sources of direct payments from the government to those with sight loss include the Disability Living Allowance for those under the age of 65 and the Attendance Allowance for those aged 65 and older.(People with partial sight and blindness may also be eligible to receive the Severe Disability Premium and Enhanced Disability Premium. However due to lack of data these were not included in the analysis. Although this may underestimate the total direct payments it is expected that it will not be significant. For example, to receive the Severe Disability Premium the person must be on the middle or higher rate of the DLA care component. Although data from DWP suggests around 6.7% receive the higher rate and 36.8% receive the middle rate (DWP, 2008), alternative criteria must also be met such as the person may have no non-dependent living with him/her or have anyone claiming Carer’s Allowance for looking after him/her (AFBP, 2008).) These payments are provided to people who need help with personal and home services and supervision for part of the day or frequently throughout day and night. Additional payments are made through the Employment and Support Allowance (ESA), which was introduced on 28 October 2008 and replaced the Incapacity Benefit, Severe Disablement Allowance (SDA) (The Severe Disablement Allowance was abolished to new applicants in 2001 however those receiving it in 2001 are still eligible to receive the allowance.) and Income Support on grounds of incapacity for work. Also, people with sight loss may receive payments through Pension credits, which are available to those over 60 who have low income.

The government also provides direct payments to informal carers through a means tested Carers Allowance (CA) to those providing informal care for at least 35 hours a week to someone who is receiving the Disability Living Allowance or the Attendance Allowance.

Table 4-8 shows the estimated total direct payments made to people with sight loss and their carers in the UK as at February 2008. In total there was £397.22 million spent in direct payments from the government to people with sight loss. This was made up of £163.79 million for the DLA, £149.31 million for the AA, £51.19 million for the ESA, £13.91 million for the SDA, and £19.01 million for the CA.

Multiplying the sum of the total direct health care system costs and the direct payments made by the public sector (Costs incurred by the private sector have been removed from this calculation as it does not represent additional tax revenue that must be generated by the government.) by the marginal cost of raising additional funds (£0.12) provided a total estimate of £268.59 million in deadweight loss in 2008 that is a direct result of partial sight and blindness.

Table 4-8: Total Direct Payments To People With Sight Loss And Informal Carers, By Direct Payment Type 2008

Table 4-8 RecipientsNumber

Rate(£ per year)

Total£million

Disability Living Allowance (DLA)Higher rate 4,390 4,911.86 (Note

A)21.56

Middle rate 24,010 3,330.36(B) 79.96Lower Rate 29,700 1,858.37(C) 55.19Nil rate 7,180 985.50(D) 7.08Total – DLA 65,280 n.a. 163.79Attendance Allowance (AA)Low and medium care (low rate)

35,380 2,337.56(E) 82.70

High care (high rate) 19,080 3,490.96(F) 66.61Total – AAA 54,460 n.a. 149.31Employment and Support Allowance (ESA)(L)Short term (low) 490 3,492.53(G) 1.71Short term (high) 500 4,069.23(H) 2.03Long term 9,280 5,112.09(I) 47.44Total – ESA 10,270 n.a. 51.19Severe Disablement Allowance (SDA)(L)

3,950 3,521.73(J) 13.91

Carers Allowance (CA) 6,980g 2,724.0(K) 19.01Total 140,940 n.a. 397.22Note: (A) Based off £94.20 per week (B) Based off £63.87 per week (C) Based off £35.64 per week (D) Based off £18.90 per week (E) Based off £44.83 per week (F) Based off £66.95 (G) based off £66.98 per week (H) Based off £78.04 per week (I) Based off £98.04 per week (J) Based off

£67.54 per week (K) Calculated by multiplying the proportion of people receiving DLA and AA for blindness (1.46 per cent) by the total number of claimants for the Carers Allowance (L) As the ESA commenced on the 28th October 2008 there is currently no data on ESA. However payments have been proxied using data from Incapacity Benefit and Severe Disablement Tables.Source: DWP (2008) and Access Economics calculations.

4.5 Summary Of Indirect CostsThe total of indirect costs attributable to partial sight and blindness in the UK amounted to £4,325 million in 2008. A breakdown of these costs is shown in Table 4-9.

Table 4-9: Summary Of Indirect Costs 2008

Table 4-9 £ millionLower employment 1,626.70Absenteeism 79.85Premature mortality 2.38Informal care costs 2,029.70Devices and modifications 336.5Deadweight loss 268.59Total 4,343.72Source: Access Economics calculations.

5. Burden Of DiseaseAdults experiencing sight loss will experience an associated loss in the quality and length of life. Consequently, the total stock of health capital will be reduced, which will be commensurate with the prevalence and severity of sight loss within the UK. As individuals place a value on their health (for example, people are willing to purchase an increase their health through treatment or to reduce the risk of experiencing poor health), the value of the reduced stock of health capital due to partial sight and blindness can be estimated.

This chapter estimates the value of a reduction in the stock of health capital in the UK adult population from reduced health and premature death related to partial sight and blindness in 2008. The method to quantify the reduction in the stock of health capital is the global burden of disease methodology developed by the World Health Organisation (Murray and Lopez, 1996). The method to value a reduction in the stock of health capital has been based off

Mason et al (2008) using estimates of the value of a statistical life derived from the UK Department of Transport.

5.1 Methods Used For Measuring And Valuing The Burden Of DiseaseTraditionally, measurement of health outcomes that combine duration and quality of life has been undertaken using the quality adjusted life year (QALY). The QALY was developed based off a multi-attribute utility theory framework under strict conditions (Sassi 2006), and has since been used as a standard in cost effectiveness analysis (Drummond et al 2005).

In the early 1990s, the multi-attribute utility framework used for the development of QALYs provided a basis for the development of the disability adjusted life year (DALY) by the World Health Organisation. DALYs were developed as the measurement unit to quantify the non-fatal health outcomes, labelled the burden of disease and injury, on populations around the world for the Global Burden of Disease Study (Murray and Lopez, 1996). Methods and data sources regarding the development of DALYs are detailed further in Murray and Acharya (1997) and Murray et al (2001).

Rather than measuring the healthy part of life associated with a condition (as in a QALY), the DALY was developed to measure the disability imposed on an individual. Thus a DALY is a negative concept, measuring the loss in a healthy life year.

DALY weights were measured on a scale of zero to one, where a zero represented a year of perfect health and one represented death. Other health states associated with specific conditions were attributed values between zero and one by a reference group convened at the WHO on the basis of a person trade-off method for measuring health state preferences (Murray and Acharya 1997). For example, a disability weight of 0.02 for mild sight loss can be interpreted as losing 2 per cent of a person’s quality of life relative to perfect health. This represented a departure from the derivation of QALY weights, which rely on preference-based health related quality of life measures derived from population samples or patients, and thus represent individual preferences rather than social preferences.

Access Economics has adopted a DALY approach in this report for consistency with our other international reports on the economic burden of sight loss (in the US, Australia, Canada and Japan). Because DALY weights are objective and consistent across countries, they are preferred by Access Economics, as well as more broadly, for example, by the WHO. For the

purposes of application in the UK, DALYs can be considered broadly comparable with QALYs (a DALY is essentially a QALY with a pre-agreed weight).

Under the DALY framework, the total burden of disease for an individual with a condition is the sum of the mortality and morbidity components associated with that condition over time, including the years of healthy life lost due to disability (YLDs), and the years of healthy life lost due to premature death (YLLs). The total burden of disease from a condition on society can therefore be represented by aggregating DALYs of all individuals with the condition.

As total DALYs are not financial they are not directly comparable with monetary costs and benefits associated with a specific condition. In an economic evaluation of public programs, a monetary conversion of the loss in healthy life is typically used to ascertain the cost of a condition so the net benefit or cost of a health intervention can be determined. This also allows benefit cost ratios to be calculated so comparisons can be made across all types of programs, not just those associated with changes to health.

In general there are two ways to estimate the value of a change in the stock of health capital using survey techniques. The first is to directly measure the willingness to pay for a change in the health status under investigation using a choice based approach, such as contingent valuation or discrete choice methods (for example, conjoint analysis and choice modelling) (Gyrd-Hansen 2005).

The alternative is to model the WTP for a year of healthy life from existing value of a statistical life (VSL) currently used in the public arena. The VSL is generally derived from the WTP of individuals to avoid small changes in the risk of various health states, including (often) death. As this is arguably a similar context to deriving WTP for changes to morbidity, VSL estimates can be applied to summary measures of health such as QALYs and DALYs (Mason et al 2008).

This study used a modelling approach derived from Mason et al (2008) to estimate the value of a year of perfect health. Their study uses a VSL derived from the UK Department for Transport (which is also recommended for use by the Health and Safety Executive ) (Mason et al 2008). The VSL was estimated to be £1.43 million in 2005 prices, derived by asking the public about their WTP for reduction in death from road safety improvements using a contingent valuation/standard gamble approach (Department for Transport, 2007).

After adjusting for quality of life, discounting using a rate of 1.5 per cent (the recommended rate of pure time preferences by Her Majesty’s Treasury), and adjusting for the value of consumption forgone due to death in the Department for Transport VSL estimates, the value of a year of perfect health was estimated to be £70,896 (in 2005 prices) (Mason et al 2008). This estimate has been used as a proxy for the value of a DALY in this study, but has been adjusted to 2008 prices using UK CPI to give £76,866.

5.2 Burden Of Disease From Partial Sight And BlindnessThe Global Burden of Disease methodology developed by the WHO (Murray and Lopez, 1996) was used to quantify the loss of wellbeing and quality of life associated with sight loss. Disability weights for mild, moderate and severe sight loss were based on the weights derived from the global burden of disease study (WHO 2004). These are: 0.02 for mild sight loss; 0.17 for moderate sight loss; and 0.43 for severe sight loss (blindness).

The total burden of disease of sight loss in the UK was calculated using the methodology presented in Section 5.1. Prevalence estimates of sight loss in the UK were derived from Chapter 2. The total burden of disease includes two components, the Years of healthy life Lost due to Disability (YLDs) and Years of Life Lost due to premature death (YLLs). Both of these are presented in more detail below.

5.2.1 Years Of Healthy Life Lost Due To DisabilityYLDs from partial sight and blindness in the UK was calculated by multiplying the number of people with sight loss by the disability weight associated with the severity of the sight loss. It is assumed that all people with partial sight or blindness in 2008 experienced their condition for the entire year. Table 5-1 summarises the burden of disease (years of healthy life lost) from partial sight and blindness in the UK for 2008.

As shown in Table 5-1, around 189,039 DALYs will be lost due to disability associated with partial sight and blindness in 2008. Of this, 64.2 per cent will be experienced by females. Figure 5-1 breaks down the share of the burden of disease across conditions. It shows that AMD has the largest burden, accounting for around 31 per cent, which is closely followed by Refractive Error, which accounts for around 29 per cent of the total burden of disease. This is despite the fact that there are significantly more people with Refractive Error in the UK compared to those with AMD (960,758 people compared to 299,886), suggesting AMD imposes a much greater burden per person.

Diabetic retinopathy had the lowest share of the burden of disease, accounting for around 6 per cent.

Figure 5-2 breaks down the burden of disease by severity of partial sight for each condition. It shows that although AMD and Refractive Error contribute similar proportions to the total burden of disease, their burdens are derived from different sources. For AMD, most of the burden of disease is due to the relatively large proportion of people who are blind due to AMD. In fact, blindness contributes to around 80.5 per cent of the total burden of disease. In contrast, only 3.5 per cent of the total burden of disease for Refractive Error comes from blindness and of this, around 71 per cent is derived from those with moderate sight loss.

In order to derive the total cost associated with the years of healthy life lost due to disability, total DALYs were multiplied £76,866 (the value of a year of perfect health discussed in Section 5.1). This provided an estimate of £14.53 billion for the total cost associated with the years of healthy life lost due to disability in 2008.

Table 5-1: DALYS Associated With Disability From Partial Sight And Blindness In The UK 2009

AMD Cataract DR Glaucoma RE Other TotalMales

18- 39 - - 117 - 932 120 116940-44 - 24 454 433 766 135 1,81245-49 - 22 416 396 993 159 1,98750-54 - 271 954 362 966 181 2,73455-59 36 434 908 344 1,291 241 3,25460-64 36 699 900 1,061 2,174 375 5,24665-69 190 907 1,120 1,279 2,582 469 6,54670-74 490 1,038 947 1,560 2,811 568 7,41475-79 3,244 781 1,172 1,084 2,373 705 9,36080-84 5,268 913 605 1,221 2,532 922 11,46285-89 5,128 1,563 46 1,060 2,466 1,129 11,393≥ 90 2,843 661 3 139 985 664 5,295Total (M) 17,235 7,313 7,642 8,939 20,871 5,668 67,672Females18- 39 - - 117 - 932 120 116940-44 - 23 208 355 999 154 1,73945-49 - 22 193 329 1,263 184 1,99150-54 - 339 488 357 1,235 208 2,62655-59 37 590 467 342 1,593 279 3,30860-64 37 1,001 471 1,022 2,629 442 5,60265-69 511 1,440 518 1,213 2,927 568 7,17670-74 919 2,694 463 1,305 3,399 658 9,43875-79 5,674 2,449 549 1,340 4,573 2,162 16,74780-84 10,867 2,744 468 1,615 5,296 2,510 23,50185-89 12,580 4,997 283 1,923 5,277 2,578 27,638≥ 90 10,865 2,440 68 1,505 3,698 1,856 20,432Total (F) 41,490 18,739 4,293 11,306 33,821 11,719 121,367Total 58,725 26,052 11,934 20,245 54,691 17,387 189,039


Figure 5-1: Share Of The Burden Of Disease Across Conditions 2008

Condition %AMD 31Cataract 14Diabetic retinopathy 6Glaucoma 11Refractive Error 29Other 9Source: Access Economics calculations.

Figure 5-2: Burden Of Disease Across Conditions, By Severity Of Sight Loss, 2008 in DALYs

Condition Mild Moderate SevereAMD 2000 8000 42000Cataract 3000 10000 11000Diabetic retinopathy

500 3000 7500

Glaucoma 1000 3500 15000Refractive Error 15000 3500 2000Other 1000 6000 8000


5.2.2 Years Of Life Lost Due To Premature DeathThe total number of deaths associated with partial sight and blindness was calculated using the same methodology outlined in Section 4.1.3. The estimated total number of deaths due to partial sight and blindness is shown in Table 5-2.

Assuming the average life expectancy for males and females in the UK is 79 years29 (OECD, 2007), the value of a year of perfect health is £76,866 (as discussed in Section 5.1), and a discount rate of 1.5 per cent, the present value of the years of life lost due to premature death associated with partial sight and blindness was calculated as £978 million in 2008.

Table 5-2: Estimated Number Of Deaths Due To Sight Loss 2008

People with sight

loss

Deaths per 1000

Deaths per 1000

attributable to sight

loss

Total deaths due to

sight loss

Discounted value of life lost

Male £ million18-19 1,948 0.97 0.02 0.01 0.0320-39 24,089 0.97 0.02 0.46 1.2340-49 43,677 2.55 0.05 2.19 4.4650-54 26,804 3.6 0.07 1.9 3.2255-59 35,710 8.9 0.17 6.25 8.9560-64 55,654 8.9 0.17 9.74 16.5265-74 153,757 24 0.47 72.53 49.0275-84 172,160 67.4 1.32 228.08 91.8985+ 139,709 171.6 3.37 471.23 173.23Total (M) 653,508 n.a. n.a. 792.39 348.56Female18-19 1,655 0.53 0.01 0.02 0.0620-39 21,654 0.53 0.01 0.23 0.6140-49 50,221 1.65 0.03 1.63 3.3250-54 30,840 2.4 0.05 1.45 2.4655-59 41,399 5.6 0.11 4.56 6.5360-64 65,557 5.6 0.11 7.22 12.2565-74 181,918 15.4 0.3 55.07 37.2275-84 330,470 48.1 0.95 312.44 125.8885+ 400,164 152.7 3 1,201.08 441.54Total (F) 1,123,878 n.a. n.a. 1,583.70 629.87Total 1,777,386 n.a. n.a. 2,376.09 978.43Note: Discount rate = 1.5 per centSource: ONS (2005) and Access Economics calculations.

5.2.3 Value Of A Loss In The Stock Of Health Capital To Sight LossThe total cost associated with the burden of disease consists of the burden associated with years of healthy life lost due to disability and years of life lost due to premature death. Using the estimates presented in the last two sections, the total cost is estimated to be £15.5 billion in 2008.

6. Projection Of Health Care System Costs And Indirect CostsDirect and indirect health care system costs have been projected to 2013. Within these projections, it has been assumed that the demand for health care services grows in line with the expected change in prevalence of each condition outlined in Section 2.4. Furthermore, it has been assumed that the price of health care services, devices and modifications, and wage rates grow at an annual inflation rate of 2.01 per cent, which is the average inflation rate for the five years proceeding 2008 (Statistics UK, 2008a).

However, due to the uncertainty of the expected utilisation of new products (for example, Lucentis), any expected change in the treatment of eye conditions in the next five years has not been incorporated within the projections. This also includes the recent shift towards a personalisation approach within the health care system and social services. The approach includes greater early intervention and prevention, and greater control for individuals over the types of support and settings within the delivery of social care in the UK (DoH 2008c). As the approach will provide greater autonomy for individuals to spend budgets, the total impact of a shift towards more personalised services on future costs is difficult to gauge.

Projected costs are shown in Table 6-1 and Table 6-2 respectively, and total cost projections are shown in Figure 6-1. In summary, costs are expected to grow by an annual average growth rate of 3.95 per cent over the next five years, totalling around 21.4 per cent. It is projected that in 2013 direct health care system costs will be £2.60 billion and indirect costs will be £5.27 billion, totalling around £7.88 billion.

Table 6-1: Projected Health Care System Costs Due To Partial Sight And Blindness In The UK

Table 6-1 2009£million

2010£million

2011£million

2012£million

2013£million


613.63 637.02 663.72 691.23 719.57


525.90 545.94 568.82 592.39 616.68


163.69 169.93 177.05 184.39 191.95


501.10 520.20 542.00 564.46 587.61


25.98 26.97 28.11 29.27 30.47


14.48 15.04 15.67 16.31 16.98


315.43 327.45 341.17 355.31 369.88


60.27 62.57 65.19 67.89 70.68

Total 2,220.50 2,305.11 2,401.73 2,501.27 2,603.82Source: Access Economics calculations.

Table 6-2: Projected Indirect Costs Due To Partial Sight And Blindness In The UK

Table 6-2 2009£million

2010£million

2011£million

2012£million

2013£million

Lower employment 1,684.04 1,748.21 1,821.49 1,896.98 1,974.76Absenteeism 82.66 85.81 89.41 93.12 96.94Premature mortality 2.46 2.56 2.66 2.78 2.89Informal care costs 2,101.25 2,181.32 2,272.74 2,366.94 2,463.98Devices and modifications 348.36 361.64 376.79 392.41 408.50

Deadweight loss 278.06 288.65 300.75 313.22 326.06Total 4,496.84 4,668.20 4,863.85 5,065.44 5,273.12


Figure 6-1: Projected Total Costs Due To Partial Sight And Blindness In The UK in £ (millions)

2008 2009 2010 2011 2012 2013Health system expenditure

2144.89 2220.50 2305.11 2401.73 2501.27 2603.82

Other 4,343.72 4,496.84 4,668.20 4,863.85 5,065.44 5,273.12Total 6,488.61 6,717.34 6,973.31 7,265.58 7,566.71 7,876.94


7. Internal ComparisonsIn addition to this study, Access Economics has estimated the economic cost of partial sight and blindness in Australia (Access Economics 2004), United States (Access Economics 2006), Japan (Access Economics 2008a), and Canada (Access Economics 2008b). This chapter provides a comparison of these studies to the economic cost of partial sight and blindness in the UK adult population.

In order to ensure comparisons can be made directly, estimates from each report have been inflated to 2008 prices using annual changes in CPI for each country and converted to Sterling using 2008 purchasing power parities sourced from the OECD. (Annual change in CPI for each country was sourced from http://stats.oecd.org/wbos/Index.aspx?QueryId=8855 (accessed 19 February 2009), while purchasing power parities for 2008 were sourced from http://www.oecd.org/dataoecd/61/54/18598754.pdf (accessed 19 February 2009))

Although each study has used a prevalence based approach, it must be noted that due to variability in availability and quality of data relating to each country, alternative methodologies have been used in estimating costs across countries. For example, Australia has detailed data on health care expenditure relating to partial sight and blindness that can be used to undertake a top-down approach. The UK has detailed inpatient and outpatient expenditure that has been used in a top-down approach, but for other areas of the health care system a bottom-up approach was required. A bottom-up approach was used to estimate all health care costs for Canada, Japan, and the US. As a consequence, the variance in methodologies must be taken into consideration when comparing estimates.

Prevalence of partial sight and blindness and costs per person with partial sight or blindness for each country are shown in Table 7-1. In the case of the UK, figures represent the cost per adult with partial sight or blindness while all other countries relate to the total prevalence and costs of people with partial sight or blindness.

In summary, it has been estimated that the UK has the least cost per person with partial sight or blindness, totalling around £12,456. Australia had the next lowest estimated cost, at an equivalent of £17,428 per person, while the US has the greatest cost, estimated at £35,386 per person with partial sight and blindness.

Table 7-1: International Comparison Of The Economic Cost Of Partial Sight And Blindness (Figures expressed in £ equivalent and 2008 prices)

Table 7-1 UK Australia US Japan CanadaPrevalence of VI (million)

1.77 (b) 0.48 3.56 1.64 0.82

- % of pop’n 2.93 2.37 1.21 1.28 2.47Note: UK prevalence relates to people 18 years and older

Table 7-1Health system expenditure

UK£

Australia£

US£

Japan£

Canada£

Inpatient 335.6 899.1 3,341.9 763.7 1,121.4Outpatient 287.7 324.3 1,069.9 2,651.4 naEmergency na na 322.5 na naPharmaceuticals 89.5 369.5 2,098.5 586.5 421.9Optometry 274.1 328.1 227.8 na 2,608.5Residential care 172.5 177.8 201.4 165.0 333.1Eye care research 7.9 64.4 154.9 336.0 28.1Community care na na 3,298.7 2,975.2 naOther health 47.2 1,061.0 2,836.7 268.2 1,951.9Indirect costsVisual aids 190.5 656.1 70.8 0.6 228.4Care 1,149.3 1,494.7 na na 518.7Lower employment 921.1 3,151.6 566.7 1,777.8 3,040.0Premature mortality 1.3 9.4 2.0 28.1 2.5Dead weight losses 152.1 367.5 34.7 684.2 1,315.6Other productivity losses 45.2 na 22.7 158.8 274.6

Burden of disease 8,782.2 8,524.7 21,137.2 20,447.9 8,768.4Total costs 12,456.5 17,428.2 35,386.4 30,843.5 20,613.1Note: All figures are pounds per person with sight loss per year

8. Case StudiesIn addition to estimating the economic cost of partial sight and blindness in the UK adult population, four hypothetical interventions were evaluated to estimate their potential cost effectiveness. These focused on four areas identified as most relevant for current policy, and include: promote the prevention of eye injuries; improve access to integrated low vision and rehabilitation services; increase regular eye tests for the older population (?60 years); and increase access to eye care services for MEGs.

Within all program interventions four distinct areas were investigated. These included inputs into the intervention and their associated costs (for example the cost associated with developing and implementing a new program), outputs from the intervention (for example, an increase in access to new services), the outcomes associated with the outputs (for example, a reduced risk of partial sight and blindness) and the adoption rate of the new intervention.

All four interventions consist of an educational program to increase knowledge of eye conditions and eye care services, although each educational campaign was assumed to be targeted at different populations. Consequently the total cost for each program differs across interventions. However, there was a distinct lack of data available from the UK on the cost of a typical educational program and the impact of a program to change behaviour towards eye care services.

Instead, an intervention known as Vision Initiative (held in Victoria, Australia) was used as a comparable public health campaign (Müller et al 2007). Vision Initiative was a public health program aimed at preventing avoidable vision loss and blindness for those living in Victoria, Australia. The program targeted the over 50 population and at risk of eye disease (noticed a change in vision, smokers, people with diabetes or who had a family history of eye disease), and consisted of messages and advertisements through television, radio, newspaper and 50 publications. The estimated proportion of the target audience of whom the campaign reached was 64 per cent (Müller et al 2007). Of those, 27 per cent noted that that the public health campaign messages changed the way they looked after their eyesight. It was estimated that the program cost $A0.116 per person targeted. To apply this cost to the hypothetical programs presented in this study, it was converted into Sterling using a purchasing power parity of 2.15 derived from the OECD (http://www.oecd.org/dataoecd/61/56/39653523.xls, accessed 17 November

http://www.oecd.org/dataoecd/61/56/39653523.xls

2008.) giving an estimated cost of £0.054 per person targeted. This may seem like a small cost but it must be remembered that it represents the cost per person targeted through media campaigns that have a wide reach (for example, television).

As data to develop the economic evaluations were relatively scarce, a sensitivity analysis using Monte Carlo simulation has been undertaken for each intervention. This allowed the development of confidence intervals surrounding results and information on the sensitivity of results to specific parameters, thereby enabling a more transparent evaluation. Monte Carlo simulation is a well known technique used to determine the sensitivity of model outputs from key model inputs. It iteratively replaces numbers attached to key inputs with random numbers drawn from a specified distribution (in these simulations there were 10,000 draws from each distribution), where the type of distribution, the upper and lower bounds on the distribution, and the number of iterations are chosen by the analyst. The Monte Carlo simulation provides a distribution around chosen outputs from which sensitivity of outputs to inputs can be determined. The program used to undertake the Monte Carlo simulations was @Risk.

8.1 Promote The Prevention Of Eye InjuriesOcular injuries can occur in the workplace, at home, while at leisure or in the community. Injuries sustained to the eye can require accident and emergency (A&E) treatment, admission to hospital and return visits to an outpatient clinic or PCPs. Eye injury can result in direct health care system costs (NHS and private), indirect costs such as expenditure on vision aids and productivity losses, and costs to the individual as a result of permanent partial sight and blindness.

Within this economic evaluation it has been assumed that an educational program similar to that presented in Müller et al (2007) is undertaken. The aim of the program is to increase the awareness of the risk associated with eye injuries in order to change the behaviour of individuals in the work place and in leisure activities. The target group is the entire population over the age of 15. (It is assumed that those under the age of 16 are notified the risks of eye injuries through adults.) The educational campaign consists of media messages through national and regional TV, radio, and newspapers, women’s magazines, trade magazines, sport magazines, and online media (for example, news services). Using a cost of £0.054 per person targeted, the total cost of a campaign is estimated to be £2.74 million in 2008 prices.

The benefits of a program are the costs that are avoided from reduced eye injuries. It has been assumed that the majority of costs are direct hospital costs, productivity loss, and deadweight loss. Costs associated with informal care, devices and modifications, and reduced quality of life have not been included because permanent damage from eye injuries occurs to only one eye in the majority of cases. For example, in a study of A&E ophthalmic attendances in Scotland between 1991 and 1992, Desai et al (1996a) note that ocular trauma is predominantly uni-ocular, and of the eye injuries presented in their study, bilateral ocular injury occurred in only 6 per cent of patients. None of these patients were bilaterally blind due to an eye injury (Desai et al 1996b). Consequently, it is assumed that people can still function properly. Although it is expected that a quality of life gain is received through avoiding injuries (for example, the temporary pain of an injury is avoided even if it does not result in permanent damage), this expected gain has not been quantified in this study.

It is assumed that 64 per cent of people see the message within the educational campaign and of these people, 27 per cent change their behaviour to avoid eye injury (Müller et al, 2007). It has also been assumed that people take heed of the messages for one year and then revert back to their old habits. Consequently, benefits in the form of avoided health care costs, avoided productivity loss, and avoided deadweight loss only last for a year. Of course, avoiding permanent eye damage in one eye provides continual benefits to an individual, but these have not been quantified due to the lack of data on disability weights associated with partial sight and blindness in one eye.

8.1.1 Eye Injuries In The WorkplaceIn recent years there has been a downward trend in the number of ocular injuries in the UK workplace. Table 8-1 shows eye injuries have decreased from 3,497 in 2001-02 to 2,529 in 2007-08. According to the Health and Safety Executive, a total of around 22,000 eye injuries occurred in the UK workplace between 2000 and 2008 (compared to 140,000 workplace injuries) (HSE, 2008c). However, these figures are likely to be an underestimate as some incidents are not reported.

Literature suggests it may be possible to reduce workplace eye injuries in the UK as recommended use of protective equipment (such as glasses, goggles and shields) is low. For example, Thompson and Mollan (2009) showed that of those eye injuries which occurred in the workplace and were presented to an A&E hospital in Scotland, 56 per cent were not wearing eye protection.

Table 8-1: Estimated Number Of Eye Injuries In The UK Workplace

Table 8-1 2001-02

2002-03

2003-04

2004-05

2005-06

2006-07

2007-08

Employee 3,055 2,979 3,030 2,700 2,607 2,334 2,125Self-employed

47 43 63 48 72 73 48

Member of the public

395 387 376 356 419 344 356

Total 3,497 3,409 3,469 3,104 3,098 2,751 2,529Note: 2007-08 figures are provisional estimatesSource: Health and Safety Executive pers. comm., 22 January 2009

Several approaches have been identified to reduce eye injuries within the workplace. A study of Taiwanese workers recommended a combination of compulsory wearing of eye protection, a good level of education, management of work safety, and employee commitment to safety and health (Ho et al, 2008). Lipscomb (2000) reported a decrease in eye injury in the United States as a result of positively reinforcing the use of eye protection, suggesting policy change alone can be effective in improving the use of eye protection and subsequently reducing eye injuries. Thompson and Mollan (2009) found that 83 per cent of UK employees who were aware of regulation were compliant, which suggests an intervention to raise awareness amongst at risk employees of existing regulations to use protective equipment may be beneficial. Enforcing employer responsibilities to promote employee use of eye protection is likely to enhance the effects.

8.1.2 Eye Injuries Associated With Leisure ActivitiesIn addition to work activities, eye injuries occur during leisure activities. Desai et al (1996a) found that the majority of people presenting eye injuries were unaware of the risks.

It is likely that most eye injuries that occur during leisure activities could have been prevented through the use of protective eye equipment. For example, 49 per cent of patients with eye injury from the industrial workplace were aware of the risks associated with eye injury, compared to 15.2 per cent of people with eye injuries occurring in sporting activities and 5.6 per cent of people with eye injuries occurring in the home. MacEwen (1989) reported that of patients presenting at an eye casualty department in Glasgow, none of the patients with eye injury from sport wore protective equipment. Bhogal et

al (2006) found that none of the patients with an eye injury due to ‘DIY’ wore protective equipment.

8.1.3 Total Number Of Eye Injuries In The UKHospital Episode Statistics show there were 223,551 A&E attendances for ophthalmic conditions in England for 2007-08 (NHSIC, 2009). Approximately 38 per cent to 52 per cent of A&E attendances for ophthalmic conditions are the result of eye injury (Vernon 1983, Chiapella and Rosenthal 1985). Assuming a mid-point of 45 per cent, it was estimated that around 101,000 ophthalmic attendances were for eye injuries in England. After scaling33, the total number of ophthalmic A&E attendances for the UK was estimated at 120,000 for 2007-08. This is shown in Table 8-2, along with the estimated number of hospitalisations and the severity of sight loss due to eye injury.

Table 8-2: Estimated A&E Visits, Hospitalisations, And Severity Of Eye Injury, 2007-08

Table 8-2 A&ENo.

OutpatientC No.

InpatientNo.

Severity of eye injury <6/12

Severity of eye injury 6/18 to

6/60

Severity of eye injury <6/60

Work 83,678 27,405 1130 42 8 34Leisure activities

21,907 7,175 296 64 12 52

Sport 2,753 902 37 34 6 27Assaults 2,275 745 31 37 7 30Contact lens injury

2,753 902 37 - - -

Unknown 6,345 2,078 86 37 7 30Total 119,712 39,206 1,616 213 40 173Source: NHSIC (2009), Vernon (1983), Chiapella and Rosenthal (1985), Desai et al (1996a and 1996b) and Access Economics calculations

In a survey of 5,671 patients with eye injuries presenting to an eye casualty department in the UK, MacEwen (1989) showed that the majority of eye injuries were due to work related incidences. Figure 8-1 shows the proportion of eye injuries by activity as found in the survey. The severity of eye injuries in the UK varies considerably. MacEwen (1989) noted that only 2 per cent to 3 per cent of all eye injuries require hospital admission, and that the majority of eye injuries are minor, affecting the peri-orbital structures or the ocular

surface. In a more recent study, Desai et al (1996b) noted that between 0.9 per cent and 1.8 per cent of A&E ophthalmic attendances in Scotland were serious enough to warrant hospital admission.

For the purposes of this study it has been assumed that the number of A&E attendances requiring hospital admission is 1.35 per cent (the midpoint of Desai et al (1996b)), which equates to around 1,600 in 2007-08 (Table 8-2). This may be an underestimate of the true number of hospital admissions for eye injury. For example, Desai et al (1996b) estimated that the cumulative incidence for hospitalised ocular trauma in one year is 8.14 per 100,000 people. This equates to around 5,000 hospitalisations in 2007-08 using UK population data. However, the difference concords well with a downward trend in total UK workplace injuries lasting 3 days or more that has occurred since 1989-90 (HSE 2008c).

Despite the higher prevalence of work related injuries, the home was the highest risk activity for a blinding injury, accounting for around 52 per cent of injuries compared to 24 per cent occurring in the workplace (Desai et al 1996a). In a survey of patients presenting eye injuries to A&E in Scotland, Desai et al (1996a) found that 13.2 per cent of patients discharged from follow-up had a visual acuity of <6/12 in the injured eye. Of these, around 2.5 per cent had visual acuity between 6/18 and 6/60, while 10.7 per cent were blind (visual acuity <6/60) in the injured eye. Applying these estimates to the number of people requiring hospitalisation, the number of people who have <6/12, 6/18 to 6/60, and <6/60 as a result of eye injury in 2007-08 was estimated to be 213, 40, and 173 respectively (Table 8-2).

Figure 8-1: Proportion Of Eye Injury Presented To A&E, By Activity

Activity D %Work 69.9Leisure Activities 18.3Sport 2.3Assults 1.9Contact lend injury 2.3Unknown 5.3Source: Macewen (1989)

8.1.4 Costs Of Eye InjuryThe cost of eye injury includes the direct health care system costs (A&E, hospital and outpatient services), productivity loss, and deadweight loss associated with raising additional taxes to fund public health care

expenditure. Costs associated with the burden of eye injuries have not been calculated as most injuries occur to one eye only, allowing the person to function normally with the other eye.

8.1.4.1 Direct Health Care System CostsAn average unit cost for all A&E minor injury services was estimated at £81 (DoH, 2008). It was assumed that 26 per cent of all A&E ophthalmic attendances resulted in an additional ophthalmic consultant-led face to face outpatient appointment (Thompson and Mollan, 2009), which cost around £101 per visit (DoH, 2008). For those that required hospitalisation, it was assumed that an additional hospital cost of £1,453 would be incurred, which is based off Reference Cost data for non-elective eye procedures (DoH, 2008). In addition, it was assumed those requiring hospitalisation also required five ophthalmic consultant-led face to face outpatient appointments throughout the year. Table 8-3 shows the estimated total cost to the NHS as a result of eye injury is around £16.0 million for 2008.

Table 8-3: Estimated NHS Costs Due To Eye Injury

Activity A&E visits£million

Outpatient£million

Inpatient£million

Total£million

Work 6.78 2.77 1.64 11.19Leisure activities

1.770.72

0.432.93

Sport 0.22 0.09 0.05 0.37Assaults 0.18 0.08 0.04 0.30Contact lens injury

0.220.09

0.050.37

Unknown 0.51 0.21 0.12 0.85Total 9.70 3.96 2.35 16.00Source: Access Economics calculations

8.1.4.2 Productivity LossAccording to HSE (2008c), around 72 per cent of eye injury results in an absence of three or more days from work (HSE, 2008c). Applying this proportion to the total number of A&E visits presented in Table 8-2, it is estimated that around 32,322 eye injuries resulted in three or more days of work in 2007-08, totalling around 258,579 days. Multiplying this by the average daily wage for males and females of £79.33 (ONS, 2007a) provides an estimated total cost in lost productivity of around £7.7 million.

8.1.4.3 Deadweight LossDeadweight loss represents the inefficiency created from taxes distorting markets. It has been assumed that for every additional pound raised in taxes to fund public health care expenditure on eye injuries there is a marginal cost of public funds to the economy of £0.12 (Kleven and Kreiner, 2006). Applying this to the total amount of public health expenditure in Table 8-3, this gives an estimated deadweight loss of £1.92 million.

8.1.5 Benefit From An Educational ProgramBenefits from an educational program are the avoided costs associated with a reduction in eye injuries. Applying the proportion of people who see the message within the educational campaign (64 per cent) and the proportion of people who change their behaviour as a result of seeing the campaign (27 per cent) gives an estimated total benefit from the program of around £4.43 million (see Table 8-4). Using program costs presented in Section 8.1 (£2.74 million) this gives a benefit/cost ratio of 1.62. That is, for every £1 spent on the educational program it is expected to avoid £1.62 in direct and indirect economic costs.

Table 8-4: Estimated Benefits From An Educational Program To Avoid Eye Injury

Table 8-4 E £millionAvoided hospital costs 2.77Avoided productivity loss 1.33Avoided deadweight loss 0.33Total benefit from program 4.43Source: Access Economics

8.1.6 Sensitivity AnalysisAs the results in the above economic evaluation rely on a number of data assumptions a sensitivity analysis using Monte Carlo simulation was undertaken. Each input variable had a triangular distribution placed around it, with a minimum and maximum chosen based on a hypothetical range of possible values for each variable. The inputs varied their means, and their minimum and maximum values are shown in Table 8-5.

The distribution of the benefit/cost ratio as a result of the Monte Carlo simulation was plotted. It showed that the minimum benefit/cost ratio was estimated as 0.98 while the maximum was estimated as 2.87. The mean cost effectiveness was estimated as 1.74. The 90 per cent confidence interval is between 1.32 and 2.25.

Table 8-5: Inputs Varied In The Monte Carlo Simulation

Variable Minimum Mean MaximumTarget population who see the campaign (%) 50 64 78

Individuals who act on the campaign, given they have seen the campaign material (%)

15 27 39

Ophthalmic A&E attendances as a result of eye injury (%)

38 45 52

Proportion requiring outpatient services (%) 15 26 37

Proportion requiring hospitalisation (%) 0.90 1.35 1.8

Cost of campaign (£ per person targeted) 0.04 0.058 0.076

Source: Access Economics

8.2 Improved Access To Integrated Low Vision And Rehabilitation ServicesLow vision strategies ensure residual vision can be optimised and the emotional aspect of vision loss is recognised. Strategies include providing access to low vision aids (LVAs) and appliances, adjusting the visual environment (for example, lighting), and providing specialised training and counselling. Low vision services are designed to ease the rehabilitative process as advice and support provide vital assistance for people with low vision to cope with practical and emotional issues and help plan for the future (Masey 1996).

As part of the Vision2020 UK project, Douglas et al (2008) surveyed 884 people with sight loss between November 2006 and January 2007 regarding their access to information, low vision services and support. Table 8-6 provides a breakdown of the services received by people with low vision in the year following their registration as having sight loss and the services received in 2006 (which includes individuals who have been registered two years or more). The results of the survey indicated that people with low vision are more likely to receive support in the year following registration compared to others who had been registered for a longer time.

Table 8-6: Types Of Services Received

Working ageYear

following registration

%

Working ageYear

prior to survey (2006)

%

Retirement ageYear


%

Retirement age

Year prior to survey

(2006)%

Training to get about outside 40 12 F 21 9

How to obtain and use technical aids

51 17 50 20

How to cope at home 31 9 27 8Offered a talking book machine/tape services

46 20 59 24

Advice on LVAs 52 19 59 23Emotional support 17 8 13 5Advice on travel 45 18 30 7Advice on benefits 39 17 40 14Advice on education/training/employment

32 17 3 14

Source: Douglas et al (2008)

Table 8-6 also highlights the marked decline in services used by people with low vision after their first year registered as having sight loss. The only increase in services used between registration and the year prior to the survey was advice on training/education/employment by people of retirement age.

Within this economic evaluation it has been assumed that an educational program similar to that presented in Müller et al (2007) is undertaken. The aim of the program is to increase the awareness of low vision and rehabilitation services in order to generate greater access. The target group is the population who have low vision (<6/12 visual acuity). The educational campaign consists of media messages through national and regional TV, radio, and newspapers, women’s magazines, trade magazines, sport magazines, and online media (for example, news services). Using a cost of £0.054 per person targeted, the total cost of a campaign is estimated to be £104,255.

It is assumed that 64 per cent of people see the message within the educational campaign and of these people, 27 per cent source access to low vision eye services (Müller et al, 2007). It has also been assumed that as a result of access to services the burden of partial sight is reduced by 20 per cent (Access Economics, 2005).

8.2.1 Low Vision Service Providers To investigate the type and location of low vision services within the United Kingdom (UK), Culham et al (2002) conducted a survey of low vision service providers in the period 1997-98. Figure 8-3 presents the composition of low vision services supplied by provider type. Hospitals with eye departments provide the most consultations to those with partial sight and blindness. This is because the majority of National Health Service (NHS) funding for people with partial sight and blindness is made available within the hospital environment. Hospitals with eye departments supply low vision clinics in the UK to help people make the best use of their remaining sight. It is often an optometrist who carries out assessment of functional vision, dispenses magnifiers and other low vision aids, as well as providing advice about lighting and other aspects of vision.

Notably, local voluntary organisations for people with partial sight and blindness are one of the most common providers of services. This result was also found in Douglas et al (2008). This may be due to statutory local authorities frequently contracting voluntary organisations to supply these services.

Figure 8-3: Proportion Of Low Vision Appointments Offered By Provider TypeProvider type %Hospitals with eye departments 65Social services/social work departments

6

Local societies/voluntary organisations for people with visual impairments

10

Opticians/Optometry practices 15Specialist teachers 3Universities with optometry/optical dispensing courses

1

Source: Culham et al (2002)

Table 8-7 highlights the significant decline in low vision service utilisation across both age groups. The most common professionals referred to in the year following registration were specialist social workers for working age people with partial sight and social workers for those of retirement age. However, both experienced substantial reductions in use across the time period considered. This difference in service use between working age and retirement age highlights the differentiated service requirements for different age groups. Table 8-7 also presents the percentage of people with partial sight and blindness who received no services at all in the year after registration and the year prior to the survey. There is a marked increase in both age groups with retirement age people receiving the least amount of assistance. This suggests that people access services when they register, but reduce their access over time.

Table 8-7: Professionals Consulted In The Year After Registration

Table 8-7 Working ageYear


Working age

Year prior to survey

(2006)

Retirement ageYear


Retirement age

Year prior to survey (2006)

Social worker/welfare worker

37% G 12% 31% 13%

Specialist social worker

43% 15% 28% 7%

Benefits advisor

19% 11% 22% 10%

Care manager 8% 3% 2% 2%Home Help/home care worker

8% 5% 10% 7%

Counsellor 7% 2% 1% 1%Employment Officer

19% 11% 0% 0%

No services at all

13% 44% 17% 55%

Source: Douglas et al (2008)

UK low vision service providers are clustered in urban areas where population densities are highest (Culham et al 2002). However, the vast majority of low vision services are provided in highly populated areas which do not necessarily have a relatively large number of residents with partial sight and blindness. Furthermore, there is a scarcity of resources in coastal and rural areas which, due to the migration of the elderly, generally have higher than usual proportions of people with partial sight and blindness.

8.2.2 Estimated Proportion Of People With Partial Sight And Blindness Not Accessing Low Vision Services

As presented in Table 8-7, 13 per cent of people with partial sight and blindness of working age and 17 per cent of people with partial sight and blindness of retirement age reported using no services at all in the year following registration. In the year prior to the study these figures increased to 44 per cent and 55 per cent respectively. Thus the utilisation of services drops off as the registration year moves further away from the current period. Some respondents were not aware of the services offered and assumed no help was available. However, others stated the difficulty of travelling long distances as the main reason for not using low vision services. Another common response was the belief that no help was required and nothing could be done.

8.2.3 Cost Of Additional Low Vision ServicesThe cost of providing additional low vision services was derived from the Gateshead project as part of the NHS Modernisation Agency’s chronic eye care services program (McLeod et al 2006). The Gateshead project aimed to provide a one-stop combined low vision service in one facility, providing eye tests, information on eye condition and entitlements, counselling and advice on employment or education available, advice on LVAs and home adaptations, and referrals to other areas of health and social care as needed (DoH 2003). Based on its activity during the 12 months to June 2006, the estimated cost per client was £345 over a one year period (£360 in 2008 prices). This included the cost of an assessment and subsequent domiciliary visit and the portion of the cost that included the rehabilitation worker role (funded in part by social services). Specifically, the costs included £31 for low vision aids, £197 for overheads including management and administration, and other costs such as wages for optometrists and rehabilitation workers and travel costs.

It is assumed that 64 per cent of the target population was reached by the campaign. Of these, 44 per cent of the working population and 55 per cent of the retired population were assumed not to be accessing services (derived from Douglas et al 2008). Of those not accessing services, 27 per cent changed their behaviour and started accessing services. Table 8-8 shows that the total estimated cost of providing additional low vision services is approximately £59.39 million in 2008 prices.

Table 8-8: Cost Of Additional Low Vision Services 2008

Age Mild£million

Moderate£million

Severe£million

Total£million

0-39 1.38 0.46 0.05 1.8940-44 0.82 0.27 0.08 1.1745-49 0.99 0.33 0.08 1.3950-54 1.04 0.40 0.13 1.5855-59 1.46 0.50 0.15 2.1160-64 2.79 1.02 0.33 4.1465-69 3.52 1.33 0.40 5.2670-74 4.05 1.69 0.48 6.2275-79 4.36 1.81 1.16 7.3380-84 5.89 2.40 1.55 9.8585-89 6.63 2.66 1.74 11.0490 and over 4.57 1.68 1.17 7.41Total 37.50 14.56 7.33 59.39Source: Access Economics calculations

8.2.4 Deadweight LossAs additional tax revenue would need to be raised to fund additional low vision services there will be an associated deadweight loss that represents a cost to the economy. Using a marginal cost of public funds to the economy of £0.12 (Kleven and Kreiner, 2006), the estimated deadweight loss is around £7.1 million.

8.2.5 Benefits Of Additional Low Vision ServicesTo estimate the benefits of the proposed educational campaign and additional low services, this study uses DALYs to measure the years of life lost due to premature mortality and the years of productive life lost due to disability. The disability weights used in this analysis are outlined in Section 5.2. Following the recommendation of Eye Australia (Access Economics 2005), the proportion of DALYs reduced through the use of low vision services is around 20 per cent. It must be noted that this is an estimate and no formal quantification has taken place. As can be seen in Table 8-9, the total DALY reduction of this campaign is estimated to be around 661 DALYs for any one year.

Table 8-9: Reduction In DALYS Per Year Due To The Campaign 2008

Age Mild sight loss

Moderate sight loss

Severe sight loss

Total

0-39 15.29 5.15 0.53 20.9740-44 9.13 H 3.02 0.89 13.0445-49 11.02 3.62 0.87 15.5150-54 11.60 4.43 1.50 17.5355-59 16.18 5.59 1.68 23.4560-64 31.06 11.37 3.65 46.0865-69 39.19 14.82 4.45 58.4670-74 45.00 18.77 5.38 69.1575-79 48.49 20.15 12.86 81.5080-84 65.55 26.75 17.29 109.5985-89 73.80 29.61 19.37 122.7890 and over 50.81 18.64 13.01 82.46Total 417.12 161.92 81.48 660.52Source: Access Economics calculations

8.2.6 Net Benefits From The CampaignAdding the cost of the campaign with the cost of additional low vision services provides an estimate of the total cost of a campaign to increase low vision service utilisation in the UK as £66.62 million. This, in conjunction with a 661 reduction in DALYs estimates the cost effectiveness of the campaign to be £100,857 per DALY avoided.

8.2.7 Sensitivity AnalysisAs the results in the above economic evaluation rely on a number of data assumptions a sensitivity analysis using Monte Carlo simulation was undertaken. Each input variable had a triangular distribution placed around the assumption used in the economic evaluation, with a minimum and maximum chosen based on a hypothetical range of possible values for each variable. The inputs varied their means, and their minimum and maximum values are shown in Table 8-10.

The distribution of the cost effectiveness ratio as a result of the Monte Carlo simulation was plotted. It showed that the minimum cost effectiveness ratio was estimated as £59,863 per DALY avoided while the maximum was estimated as £211,485 per DALY avoided. The mean cost effectiveness was estimated as £105,342 per DALY avoided. The 90 per cent confidence

interval is between £73,900 per DALY avoided and £152,900 per DALY avoided.


Variable I Minimum J Mean K MaximumTarget population who see the campaign (%) 50 64 78

Individuals who act on the campaign, given they have seen the campaign material (%)

15 27 39

DALYs reduced through use of services (%) 10 20 30


Cost of eye care services (£ per person per year) 300 360 420

8.3 Regular Eye Tests For The Older PopulationEye tests are important for detecting eye disease and refractive error, particularly for those aged 60 years and over who are at higher risk of developing partial sight and blindness. According to RNIB (2007), a large proportion of elderly people neglect to have regular eye tests due to a number of reasons, including: absence of symptoms; worries about the cost of glasses and/or lens prescription; transport restrictions; lack of awareness of the impact of eye tests and treatments on eye

disease; and lack of awareness of entitlement to free eye tests and free glasses/lens

prescriptions.

A survey of around 5,000 people in the UK aged 60 years and over found that 60 per cent of respondents gave absence of symptoms as their main reason for not having an eye test (RNIB, 2007). The same study also recommended a public awareness campaign targeting the elderly that makes the link explicit between partial sight and blindness and symptoms/non-symptoms. The costs for such a campaign would vary depending on the reach of the campaign (for example, local versus national) and the media

used within the campaign (for example, posters in doctors’ clinics, television and/or radio advertising).

The NHS offers one free eye test every two years for those aged 60 to 69 in England and Scotland, and one free eye test every year for those aged 70 years and over. In Scotland, free eye tests are given to everybody, with those aged over 60 entitled to an advanced eye health check. In 2007-08 approximately 4.86 million eye tests were provided to those aged 60 years and over in England under General Ophthalmic Services (NHS Information Centre, 2008). This suggests that less than half of people aged over 60 have an annual sight test. The RNIB presents similar figures based on survey data, estimating that 47 per cent of those aged 60 and over do not have an annual eye test (RNIB, 2007).

In addition, there have been a number of recent one-off national and local public health awareness campaigns targeting eye disease. For example, the RNIB ran the ‘Open your eyes’ campaign in 2006 to promote general uptake of eye tests, and the ‘Eye Test Action Day’ in 2006 and 2007 for the same cause. However, it is difficult to assess the impact these public awareness campaigns had on the level of uptake of entitlement to free eye tests of older people due to the lack of data.

Within this economic evaluation it has been assumed that an educational program is undertaken similar to Vision Initiative, a public health program aimed at preventing avoidable partial sight and blindness for those living in Victoria, Australia (Müller et al, 2007). It is assumed an educational program in the UK would target the over 60 population, consisting of messages and advertisements through national and regional television and radio stations, national and regional newspapers, and alternative publications such as magazines and online media outlets. The aim of a program would be to generate greater awareness and access to services in order to discover partial sight in those who would not have otherwise presented. Once previously undetected partial sight is discovered it is assumed services are used to improve their vision. Using a cost of £0.054 per person targeted, (Derived from Müller et al (2007) and converted into Sterling using PPP of 2.15) the total cost of a campaign is estimated to be £0.73 million in 2008 prices.

As a result of the education program there will be an increase in free eye tests in the elderly population (defined as those aged 60 years and over). The outcome measure is the improvement in the detection and treatment of eye disease in those aged 60 years and over through the increased use of existing entitlements to free eye tests.

Reaction to a public health campaign will depend on its persuasiveness, coverage, and presentation. Using estimates derived from Müller et al (2007) the proportion of the target audience whom the campaign reached is assumed to be 64 per cent. The number of those aged 60 and over who visit an eye specialist within the year due to the campaign is assumed to increase by 14.5 per cent.

8.3.1 Past Studies On Effectiveness Of Visual ScreeningStudies that have focused on the effectiveness of routine visual screening of the elderly suggest a lack of cost effectiveness of visual screenings for the elderly who show no symptoms. For example, Smeeth and Iliffe (1998) (An updated version was published as Smeeth LL, Iliffe S, ‘Community Screening for Partial sight and blindness in the elderly (Review)’, Cochrane Database of Systematic Reviews 2006, Issue 3, Art. No.: CD001054. DOI: 10.1002/14651858.CD001054.pub2) assessed five randomised trials of visual screening and found that it did not result in improvements in self reported visual problems. They argued that screening of asymptomatic older people in the community is not justified without tackling other obstacles to treatment such as cost, waiting lists and awareness.

Smeeth et al (2003) conducted a similar study to determine the effectiveness of screening for partial sight and blindness in people aged 75 and over as part of a multi-dimensional screening program. Their study used two groups, including: a universal screening group where all participants in the trial were invited

to complete a brief assessment followed by a detailed health assessment that included measurement of visual acuity, and

a targeted screening group where a detailed health assessment (including visual screening) was only offered to those who had a specific range and level of problems during the brief assessment.

If visual acuity was less than 6/18, they were referred to an ophthalmologist unless they had been seen by one in the previous year, or were registered blind or partially sighted.

Smeeth et al (2003) showed that screening older people for partial sight and blindness (using visual acuity measures instead of self-reported measures) as part of a multi-dimensional screening assessment offered no benefit. In the targeted group, of those who took the visual acuity test, 43 per cent had reduced visual acuity and 31 per cent were eligible for referral to an optician or ophthalmologist, compared to the universal screening group where 29 per cent had vision loss and 21 per cent could be referred. Although some people

benefited from the intervention, the study concluded that the number was small in the context of population-based screening and not sufficient to affect the prevalence of partial sight and blindness among all participants.

Jessa et al (2007) concluded that a properly funded public health campaign may encourage more elderly people to use their entitlement to a free visual screening, although it will leave many still avoiding regular eye care. Instead, the report argued for a ‘safety net’ of a battery of vision tests that include tests of visual acuity, visual field testing, low contrast visual acuity, contrast sensitivity and stereo-acuity.

However, Smeeth and Iliffe (2006) suggest the lack of effectiveness in visual screening was because visual assessment was only one component of a screening package. If visual screening were to be performed in isolation, it may produce a greater effect. Also, screening on its own could not improve vision, and subsequent intervention was required. A third factor noted by Smeeth and Iliffe (2006) was the common use of self-reported measures where participants may not have perceived their previously unreported partial sight as a ‘need’ for intervention, and therefore may not have acted on advice to seek further care. They argue for further research into strategies to improve vision of older people including research on the detection, referral, diagnosis and management of visual problems.

8.3.1.1 Prevalence Of Undetected Eye DiseaseThere is a significant proportion of the older population in the UK that have undetected partial sight and blindness. For example, Evans and Rowlands (2004) estimated that between 20 per cent and 50 per cent of older people have undetected reduced vision, with the majority of this group having correctable visual problems, such as refractive error and cataracts.

Reidy et al (1998) conducted a survey of people aged 65 and over in the North London area and set out the proportion of people with vision loss not in touch with eye care services, as seen in Table 8-11. For definitive glaucoma, the ratio of undetected to known was 3 to 1, and for suspected glaucoma, the ratio was 5 to 1. Overall 88 per cent of people with vision loss were not in touch with eye care services. A total of 698 people (45 per cent of the total sample) had visited an optometrist within the 12 months preceding the survey eye examination.

Table 8-11: People With Partial Sight And Blindness Not In Touch With Eye Care Services 2008

Eye disease CasesNumber

Proportion not in touch with eye care

services%

Cataract 451 L 88Age related macular degeneration 133 86Refractive error 136 96 (see note (a))Glaucoma: 156 81Definite cases 47 74Suspect cases 109 84Note: (a) 30 per cent had visited an optometrist during the past 12 monthsSource: Reidy et al (1998)

Reidy et al (1998) noted the prevalence of cataracts in the survey was 30 per cent although 88 per cent of these were not in touch with eye care services. The prevalence of age-related macular degeneration was 8 per cent and definite glaucoma cases 3 per cent, however 86 per cent and 74 per cent respectively of these cases were known to eye services. Overall the unmet visual need in this population-based study was 22 per cent of the population aged 65 or over.

Similarly Wormald et al (1992) found half of survey participants with low vision (visual acuity less than 6/18) were known by their doctor to have an eye complaint. However Fletcher et al (2001) argued that their most conservative estimate of people with undetected age-related macular was 35 per cent.

The prevalence of undetected mild sight loss in the UK for those 60 years and older was estimated by multiplying the proportion of people not in touch with eye care services who have partial sight (Reidy et al 1998) by this study’s estimates of the prevalence of partial sight in the UK. Estimated prevalence of undetected partial sight is presented in Table 8-12, which has been broken down into underlying causes. In total, it is estimated that there are around 857,187 people aged over 60 with undetected partial sight in the UK, amounting to around 6.32 per cent of the older population. This concords well with RNIB’s estimate of around one million people in the UK who have unnecessary sight loss due to treatable conditions (RNIB, 2008).

Table 8-12: Prevalence Of Undetected Mild Sight Loss (<6/12 to 6/18) In The UK 2008

Age AMDno

Cataractsno

DRno

Glaucomano

REno

Otherno

All VIno

60-64 3,128 7,084 2,253 200 58,457 5,531 76,65465-69 8,987 9,846 2,656 460 67,044 7,016 96,01070-74 14,175 9,151 2,300 515 75,591 8,300 110,03375-79 6,229 18,035 1,041 2,358 85,950 5,203 118,81780-84 21,217 23,594 1,557 7,296 96,693 7,552 157,90985-89 30,722 33,401 1,430 7,022 95,526 8,641 176,74290+ 31,934 21,656 300 3,542 57,826 5,766 121,023Total 116,393 122,767 11,537 21,394 537,088 48,009 857,187Source: Access Economics calculations

8.3.2 Optimal Length Of Time Between Eye ExamsThere is little evidence on the optimal length between eye tests for the elderly, but most organisations recommend that the elderly should have eye tests every one or two years.

The UK Association of Optometrists recommends that those with low-risk aged 16 to 70 should have an eye test every two years, and those over 70 years should have an annual eye test. However, it is suggested that those with a family history of glaucoma who are aged 40 years and over and diabetic patients should have an eye test every year (Association of Optometrists, 2009).

Guide Dogs (UK) recommends that those aged 40 to 69, should have a full eye examination every two years and this should increase to annual eye examinations for those over 70 (Healthy Eyes, 2008).

Taylor et al (2004) concluded that those who perceive no symptoms of eye disease, frequent routine examinations may not be cost effective. In a population cohort aged 40 and over, 38 out of 1,590 participants had reduced vision in at least one eye, and only 8 had not noticed the change in vision. Of the 24 participants had noticed a change in vision, one quarter had not sought an eye examination. Therefore only 0.88 per cent (14 out of 1,590 participants) had unrecognised vision loss over a 5-year period. The report recommended that public health campaign messages should be targeted towards those who notice a change in vision, and those at higher risk such as those with diabetes or a family history of disease. Jessa et al (2007) similarly recognised that interventions are effective for symptomatic patients but the

effects of treating older people with unreported visual problems has not been evaluated.

RNIB (2007) recommends that an eye test be taken every year for those aged over 60. According to a RNIB survey, 53 per cent of respondents aged 60 and over had their eyes tested at least once a year, 35 per cent have their eyes tested every two years, and 11 per cent had an eye test less than once every two years. Those aged between 60 and 69 had significantly fewer annual eye tests compared to those aged 70 and over, as seen in Table 8-13.

Based on RNIB’s recommendation of an annual eye test, the target group of a public health campaign would be the 47 per cent of those aged 60 and over who take an eye exam less frequently than once a year.

Table 8-13: Frequency Of Eye Tests, By Age

Age Group More than once a year

%

Once a year%

Once every two years

%

Less than once every two years

%60-69 5 35 47 1270-79 9 54 28 1080-89 12 55 23 1190+ 21 55 21 3Total 8 45 35 11Source: RNIB, 2007

8.3.3 Cost Of Not Undertaking A Regular Eye TestThere is a cost attached to those who fail to take a regular eye test as their health will deteriorate without detection and treatment. This reduction in health is measured in disability life-adjusted years (DALYs). The DALY weight for mild sight loss is 0.02, as estimated by the WHO global burden of disease project (Murray and Lopez, 1996). It is assumed that the partial sight will only be in its mild stages, where visual acuity is less than 6/12 to 6/18. It is assumed that a person would have seen an optometrist or ophthalmologist before it became moderate or severe as the vision loss would have significantly affected daily life. However, it is recognised that people with severe comorbidities (such as dementia) may not fall into this category as they cannot often communicate their needs, but it is expected these people will be a minority.

It is also assumed that each person who has not undertaken a regular eye test but has undetected mild sight loss will seek an eye test and subsequent treatment within the next five years of their own accord. (This represents an average length of time. In reality, many people will seek an eye test of their own accord in less than five years while others will wait substantially longer. The timing will depend on the disease pathway and the barriers to accessing services by the individual. Consequently, this parameter is specifically modelled in the sensitivity analysis.) That is, the impact of the program is assumed to bring an eye test forward five years. This is because the condition will become worse to a point where unrecognised partial sight by the individual becomes recognised as it starts affecting daily life.

The cost of not having regular eye tests was determined by the prevalence of undetected mild sight loss multiplied by the reduction in health over five years (length of time that person experiences the reduction in health before they seek an eye test of their own accord). This amounts to an increase of 85,719 DALYs.

8.3.4 Benefits Of An Educational CampaignThe potential benefits of an educational campaign can be measured by the expected increase in the quality of life for those people who take an eye test with partial sight and who subsequently receive treatment.

In 2007-08 there were 4,860,912 NHS sight tests provided to those aged 60 years and over in England and 290,890 in Wales under General Ophthalmic Services (NHS Information Centre, 2008). It is estimated that Scotland has around 10 per cent of the number of NHS eye tests of England, and therefore has 466,433 sight tests (NHS Information Centre, 2004). In Northern Ireland, it is estimated that there were 23,002 private eye tests and 177,413 eye tests provided by the Health Service to those aged 60 and over (Department of Health, Social Services and Public Safety, 2007). The number of NHS sight tests given to the UK older population are presented in Table 8-14. It has been assumed that all sight tests provided to the older population are funded by the NHS. Consequently, private sight tests have not been included in the analysis.

Table 8-14: Number Of Sight Tests For The Older Population In The UK 2008

Region Sight testsmillion

England 4.86Wales 0.29Scotland 0.47Northern Ireland 0.20UK 5.82Sources: NHS Information Centre (2008, 2004), DHSSPS (2007)

An increase in sight tests by 14.5 per cent (Müller et al 2007), will amount to 843,704 additional sight tests. With 6.32 per cent of the elderly population having undetected mild sight loss, the additional sight tests are expected to detect 53,311 people with partial sight. However, only a proportion of these people will have conditions that are remediable, which has been estimated by Reidy et al (1998) as 69 per cent. Consequently, it has been estimated that the program will result in a 3,678 fewer DALYs over the five years.

8.3.4.1 Costs Of Additional Sight TestsThe Department of Health sets the NHS eye test fee for England, Wales and Northern Ireland for every year. Domiciliary visits have a separate fee for the first and second patients seen at one visit, and another fee for the third and subsequent patients. The fees are shown in Table 8-15.

The Scottish Government sets its own sight test fees and is shown in Table 8-16. From 1 April 2008, the Scottish Government decided to set different fees for those aged 60 years and over as they are entitled to a more advanced eye examination.

Table 8-15: Sight Test Fee In England, Wales And Northern Ireland

Year Standard NHS Sight test£ per test

Domiciliary sight test for

first two patients

£ per test

Domiciliary sight test for subsequent

patients£ per test

1 April 2006 18.85 33.19 8.311 April 2007 19.32 34.02 8.521 April 2008 19.80 34.87 8.731 April 2009 20.26 35.67 8.931 April 2010 20.70 36.46 9.13Source: DoH (2009, 2008, 2007)

Table 8-16: Sight Test Fees In Scotland

Year Primary NHS sight test for those aged

under 60£ per test

Primary NHS sight test for

those aged 60 and over£ per test

Supplementary NHS Sight test

£ per test

1 April 2008 36 40 211 April 2009 36 44 211 April 2010 37 45 21.50Source: Scottish Government (2008)

Based on the proportion of the UK older population that will take an eye test as a result of the campaign, the total cost of additional eye sight tests as a result of a public health campaign will come to £18.07 million in 2008 prices.

8.3.4.2 Costs Of Additional TreatmentOf the 843,704 additional people who take an eye test, it is estimated that 53,331 (6.32 per cent) will have their mild sight loss detected.

Cruess et al (2008) estimated that the cost of treating AMD in the UK was £4,199, converted to 2008 values. Costs included direct vision-related costs (vision rehabilitation, optical equipment, eye doctor visits etc), direct non-vision related costs (fall- and accident-related injuries), and direct non-medical-related costs such as nursing homes and social benefits received from a visual disability. Direct vision-related costs were £1,704, direct non-

vision related medical costs were £473 and direct non-medical-related costs were £2,018.

The Guide Dogs for the Blind Association (UK) estimated the annual cost of cataracts, including treatment (surgery) and non-treatment visual related costs (welfare benefits, rehabilitation services, residential and home care support) to be £4,591 (in 2008 prices) in the base case scenario for the elderly population (Guide Dogs, 2003).

Traverso et al (2005) found that the cost of glaucoma treatment varied from £381 per year for to £888 depending on the severity of the disease. The costs included office visits, diagnostic procedures, surgery and medication. Across all stages, the average cost of treating glaucoma was found to be £577 (in 2008 prices).

The cost of diabetic retinopathy treatment was estimated assuming four laser treatments per year and a follow-up ophthalmologist visit, amounting to £1,151 per eye in 2008 values (NHS 2004). However when diabetic retinopathy is present with symptomatic disease in one eye, the other eye is also likely to have retinopathy, and the additional laser treatment required in the second eye could amount to a further cost of £830 to £1,107. Taking the average of the additional laser treatment, the estimated cost of treating diabetic retinopathy in both eyes was £2,120 per person (in 2008 prices).

The cost of refractive error was calculated using the total sum of public and private health expenditure in the UK. The total public cost of vouchers for spectacles used to correct refractive error for those aged over 18 was estimated to be £154.18 million in 2006-07, and the private expenditure on spectacles to be £70.57 million. Adjusted for inflation, the total cost amounts to £238 million in 2008 with a cost of £641 per person per year.

The cost of treating partial sight other than age-related macular degeneration, cataracts, diabetic retinopathy, glaucoma or refractive error was taken to be the average of these five types of eye diseases, amounting to £2,426.

Multiplying the detected partial sight by the proportion of remediable conditions and the costs of treatment, the total cost of treatment was estimated at £96.39 million in 2008 prices. This is shown in Table 8-17, where costs are broken down by condition type.

Table 8-17: Estimated Cost Of Additional Treatment 2008

Partial sight Additional cases detected

no

Cost of treatment£ per year

Total cost£million

AMD 7,239 4,199 (a) 30.40Cataracts 7,635 4,591 (b) 35.05DR 718 2,120 (c) 1.52Glaucoma 1,331 577 (d) 0.77RE 33,403 641 (e) 21.41Other 2,986 2,426 (f) 7.24Total 53,311 na 96.39Source: (a) Cruess et al (2006) (b) Guide Dogs (2003) (c) NHS (2004) (d) Traverso et al (2005) (e,f) Access Economics calculations

8.3.4.3 Deadweight LossAs additional tax revenue would need to be raised to fund additional sight tests and treatment there will be an associated deadweight loss that represents a cost to the economy. Using a marginal cost of public funds to the economy of £0.12 (Kleven and Kreiner, 2006), the estimated deadweight loss is around £13.8 million.

8.3.4.4 Total Costs Of A CampaignIncluding the cost of implementing a public health campaign, the additional sight tests and additional treatment of those found to have partial sight, the total cost amounts to £129.01 million in 2008, as seen in Table 8-18.

Table 8-18: Estimated Total Cost Of A Campaign To Increase Sight Tests 2008

Table 8-18 Cost£million

Public health campaign 0.73Additional sight tests 18.07Additional treatment 96.39Deadweight loss 13.82Total 129.01Source: Access Economics calculations

8.3.5 Net Benefits From A CampaignBenefits of an educational program are the avoided costs associated with the undetected partial sight and amount to a reduction of 5,331 DALYs. Given the program costs, additional sight tests and treatment, it is expected that a program to increase sight tests to those 60 years and older would result in a cost effectiveness ratio of £24,200 per DALY avoided.

8.3.6 Sensitivity AnalysisAs the results in the above economic evaluation rely on a number of data assumptions a sensitivity analysis using Monte Carlo simulation was undertaken. Each input variable had a triangular distribution placed around it, with a minimum and maximum chosen based on a hypothetical range of possible values for each variable. The inputs varied their means, and their minimum and maximum values are shown in Table 8-19.

The distribution of the cost effectiveness ratio as a result of the Monte Carlo simulation was plotted. It showed that the minimum cost effectiveness ratio was estimated as £12,733 per DALY avoided while the maximum was estimated as £74,673 per DALY avoided. The mean cost effectiveness was estimated as £26,188 per DALY avoided. The 90 per cent confidence interval is between £17,000 per DALY avoided and £41,200 per DALY avoided.


Variable Minimum Mean MaximumIncrease in the number of eye tests (%) 10 14.5 M 19

Conditions undetected – AMD (%) 43 86 95Conditions undetected – Cataract (%) 44 88 97

Conditions undetected – DR (%) 44 88 97Conditions undetected – Glaucoma (%) 37 74 83

Conditions undetected – RE (%) 48 96 98Conditions undetected – Other (%) 44 88 97Time partial sight is undetected (years) 2 5 8

Conditions that are remediable (%) 60 72 84Cost of sight test in England, Wales, N.I. (£ per exam) 15.0 19.8 24.6

Cost of sight test in Scotland (£ per exam) 35 40 45

Cost of treatment – AMD (£ per person) 3779 4,199 4619

Cost of treatment – Cataract (£ per person) 4132 4,591 5050

Cost of treatment – DR (£ per person) 519 577 635

Cost of treatment – Glaucoma (£ per person) 1908 2,120 2332

Cost of treatment – RE (£ per person) 577 641 705

Cost of treatment – Other (£ per person) 2183 2,426 2669


8.4 Improved Access To Eye Care Services For Minority Ethnic GroupsThere is evidence that low income and minority and ethnic groups (MEGs) have an increased risk of developing certain eye diseases. For example, Section 2.2.3 noted: black population has a greater risk of developing AMD compared to the

white population and Asians in younger age groups, whereas the white population has a greater risk of developing AMD in the latter years of life;

asians have a greater risk of developing cataracts compared to the black population and white population;

black and Asian populations have a greater risk of developing diabetic eye disease compared to the white population;

the relative risk of glaucoma is much higher for the black population compared to the white population;

the white population has the greater risk in developing refractive error compared to the black population; and

for other eye disease, no robust differences in relative risk as a result of ethnicity have been found.

There are a number of identifiable barriers to accessing regular eye tests by the general population. These include: lack of knowledge of the entitlement; failure to recognise the importance of regular eye tests for combating eye

disease; transport restrictions; concerns about the cost of glasses/prescription; fear of complications; and cost of the eye test for those who do not receive free eye care services

(RNIB, 2007).

However, MEGs face additional barriers to those listed above. For example, they tend to be more remote from statutory services and less well connected to mainstream service providers (Johnson and Morjaria-Keval, 2007). In addition, MEGs have language needs such as interpretation, translation and information in community languages. A lack of English language skills can hinder some MEG members from understanding the nature of eye disease, the increased risk of developing eye disease, how to access eye care services, and referral/treatment pathways (Joule and Levenson 2008). Cultural differences can also inhibit access to eye care services. For example, the stigma of blindness is common in all societies but in South

Asian communities a physical disability may be met with pity and rejection, making it difficult to overcome cultural norms (Orticio, 1994).

Although MEGs have a greater risk of eye disease the evidence suggests they do not receive the same level of access to eye care services. For example, black British communities are 20 per cent less likely to have had an eye test than the rest of the population (RNIB, 2008). A twelve month audit of selected opticians in Wales found that 42 per cent of white diabetic patients had an eye exam within the past twelve months compared to 14 per cent of ethnic patients (Woolf, 2003). Furthermore, Robinson et al (1994) suggested that even though there is a minority of people registered as blind compared to the total population that are entitled, Asians and the black population may be even more under-represented, thereby contributing to the lack of services offered to these population groups. Similarly, Barry and Murray (2005) found that the odds ratio of someone from an ethnic minority being unregistered versus someone who is white was 3.23.

A low level of access to eye care services is consistent with disparities in access to health care services for MEGs in the UK in general. Nazroo (2009) suggests evidence within the NHS reveal inequalities in access to health care between MEGs and the white population. In particular, MEGs experience: lower levels of secondary care; higher levels of dissatisfaction with care received; longer waits for appointments; poorer quality of practice infrastructure; language barriers during the consultation; lower probability of follow-up services; longer waits for referral to specialist care; and less likely of receiving specialist treatments.

According to Johnson (2004) the greatest reason for the differences in access to health care services in general is due to language barriers. For example, the inability of some MEG members to read English reduces the impact of health promotion campaigns. However, Johnson (2004) notes that language barriers are more relevant to older generations in MEGs (first generation) as a large proportion of younger MEG members have been educated in the UK.

Given the complexity of causes of inequalities, there are many types of interventions that could be used to reduce the disparity in access to eye care services for MEGs. Interventions could target individuals and specific communities in the general population, patients with conditions that impose the greatest burden, or patients with specific characteristics, such as low

income. Interventions could target the attitudes of individual health care providers or their knowledge and skills. Alternatively, interventions could target providers in a more general setting, such as within community health care settings and referral networks.

Research has found that MEGs have little knowledge about partial sight and blindness and vision services offered in their community (RNIB 2003). In research on sight loss and services in MEGs in the UK, Morjaria-Keval and Johnson (2006) found that the primary need for MEGs is providing information to improve knowledge of these subjects. They suggested that information should be provided through established communication pathways and in settings that were familiar to the MEG, such as MEG specific media and attending events organised within established community activities.

Within this economic evaluation it has been assumed that an educational program is the intervention undertaken to improve access to eye services for MEGs. The program consists of messages delivered to a target population consisting of all individuals who belong to a MEG and have partial sight and blindness. Messages are delivered through MEG specific media, such as satellite TV channels, Asian radio, local newsletters, newspapers, and churches or temples. Using a cost of £0.054 per person targeted, (Derived from Müller et al (2007) and converted into Sterling using PPP of 2.15) and multiplying it by the total population of MEGs, the total cost of a campaign is estimated to be £311,958.

It is also assumed that a tour is undertaken to specific MEG events around the UK in order to disseminate information on partial sight and blindness, eye disease, and eye care services to MEG communities. Costs include a full time co-ordinator, exhibition stand, news releases through local media, transportation, accommodation, flyers, posters, programs, travel and subsistence. It is estimated that to undertake this type of tour to ten locations throughout the year it would cost around £300,000 in 2008 prices (RNIB, pers. comm., 30 January 2009). Consequently, the total cost for an educational program targeted at MEGs is estimated to be £611,958.

Using estimates derived from Müller et al (2007) the proportion of the target audience whom the campaign reached is assumed to be 64 per cent. However, reaction to a public health campaign will not only depend on its persuasiveness, coverage, and presentation, but also on whether MEGs can navigate other significant barriers in accessing eye care services. Consequently the likely change in behaviour is expected to be less than a typical population, and for want of a better estimate, it has been assumed that half of the estimated number of those who change behaviour in Müller et

al (2007) is appropriate, which is 14 per cent. This means that around 9 per cent (or 4,983 persons) of the MEG population that has partial sight is expected to change their behaviour as a result of the campaign.

This economic evaluation assumes that as a result of the intervention there will be an increase in eye tests in MEGs across all ages, corrected vision, and the avoidance of further deterioration in partial sight. The outcome measure is the improvement in the detection and treatment of eye disease in MEGs, and the subsequent health benefits associated with improved visual acuity.

8.4.1 Prevalence Of Undetected Partial Sight In MEGsThere are a significant number of people in the UK who have undetected partial sight and blindness. However, due to the greater risks of developing certain eye conditions, and the additional barriers to eye care services faced by MEGs, it is expected that prevalence of undetected eye conditions is greater in the population.

The prevalence of undetected eye conditions for MEGs was derived by multiplying the proportion of people with partial sight and blindness not in touch with eye services (Reidy et al 1998) by this study’s estimates of the prevalence of mild and moderate sight loss within the minority ethnic population. Table 8-12 provides the estimated prevalence of undetected partial sight by condition. In total, it is estimated that around 41,200 individuals belonging to MEGs have undetected mild sight loss, and around 14,400 individuals belonging to MEGs have undetected moderate sight loss. The total prevalence of undetected partial sight amongst MEGs was estimated to be around 55,600, or 1.1 per cent of the total MEG population.

Table 8-20: Estimated Prevalence Of Undetected Partial Sight In MEGs In The UK 2008

AgeAMDMild

AMDMod

CataractsMild

CataractsMod

DRMild

DRMod

0- 4 - - - - - -5- 9 - - - - - -0-14 - - - - - -15-19 - - - - - -20-24 - - - - 3 325-29 - - - - 10 1030-34 - - - - 33 3335-39 - - - - 79 7940-44 - - 944 - 115 11545-49 - - 888 - 94 9450-54 - - 825 350 184 18455-59 109 - 887 383 112 11260-64 100 - 507 220 113 11365-69 244 44 746 317 143 14370-74 352 63 415 401 102 10275-79 100 88 546 225 35 3580-84 209 102 500 213 34 3485-89 290 125 651 254 24 2490+ 243 83 323 109 4 4Total 1,647 505 7,233 2,470 1,085 1,085

AgeGlaucoma

MildGlaucoma

ModRE

MildRE

ModOtherMild

OtherMod

0- 4 - - 318 103 22 65- 9 - - 393 128 27 80-14 - - 498 162 34 1015-19 - - 728 236 50 1420-24 - - 1,061 345 73 2125-29 - - 1,139 370 79 2330-34 - - 844 274 62 1835-39 - - 761 247 63 1840-44 311 141 1,853 602 180 5145-49 251 113 2,201 715 192 5550-54 231 104 1,720 559 175 5055-59 149 67 1,450 471 152 4360-64 297 12 2,277 740 233 6665-69 486 34 2,744 891 321 9270-74 471 31 2,462 800 312 8975-79 291 106 1,888 623 137 13780-84 283 156 1,437 473 131 13185-89 247 132 1,323 435 133 13390+ 77 41 614 202 65 65Total 3,094 938 25,711 8,376 2,442 1,031

AgeALL VI

MildAll VIMod

0- 4 339 1095- 9 420 1350-14 532 N 17215-19 778 25120-24 1,137 36925-29 1,229 40330-34 940 32535-39 903 34440-44 3,403 90945-49 3,625 97750-54 3,135 1,24755-59 2,860 1,07760-64 3,527 1,15165-69 4,685 1,52070-74 4,113 1,48675-79 2,997 1,21480-84 2,594 1,10985-89 2,669 1,10390+ 1,325 503Total 41,211 14,405Note: Mild = <6/12 to 6/18 Mod = <6/18 to 6/60Source: Access Economics calculations

8.4.2 Benefits Of Campaign Directed At MEGsThe benefit of a campaign to raise awareness of eye disease and eye care services among MEGs is the avoided DALYs (or reduction in the quality of life). This stems from two sources, including corrected vision for those conditions that are remediable (mostly cataracts and refractive error), and the avoided further reduction in visual acuity.

8.4.2.1 Corrected VisionReidy et al (1998) found that around 72 per cent of undetected partial sight and blindness cases are remediable, with the majority of these cases being refractive error and cataracts. For this study it was assumed that 72 per cent of undetected refractive error and cataracts would have their vision corrected if eye care services were accessed as a result of an educational program.

The number of people that are expected to benefit from corrected vision was calculated by multiplying the proportion of target population who are expected

to change their behaviour (9 per cent) (Calculated by multiplying the proportion of target population who will see the campaign (64%) by the proportion of people expected to change their behaviour (14%)) by the prevalence of mild and moderate correctable partial sight associated with cataracts and refractive error (As estimated by the WHO global burden of disease project (Murray and Lopez, 1996), the DALY weight for mild sight loss and blindness is 0.02, while the DALY weight for moderate sight loss and blindness is 0.17). Of those people who are legally blind as a result of cataracts and refractive error, it was assumed their partial sight could not be corrected.

It is also assumed that a person has undetected but correctable partial sight for five years before they seek an eye service of their own accord. That is, for these people an educational campaign brings their eye test forward five years. This was derived from Taylor et al (2004), who found in a five year population based study of people aged 40 years or more in the Melbourne Visual Impairment Project (Australia), the majority of those who had a change in vision over five years recognised this change.

An estimated reduction in DALYs through correcting vision was calculated by multiplying the number of people expected to benefit from corrected vision by DALY weights for mild and moderate sight loss and the length of time the partial sight was expected to last undetected without an educational campaign (five years). The estimated total reduction in DALYS is 807, which is shown in Table 8-21, broken down by condition and age.

Table 8-21: DALYS Avoided Through Corrected Vision As A Result Of The Campaign

Age Cataractsno

Refractive Errorno

Totalno

0- 4 O - 8 85- 9 - 10 100-14 - 12 1215-19 - 18 1820-24 - 26 2625-29 - 28 2830-34 - 20 2035-39 - 18 1840-44 6 45 5145-49 6 53 5950-54 25 42 6655-59 27 35 6260-64 15 55 7165-69 22 67 8970-74 25 60 8475-79 16 46 6280-84 15 35 5085-89 18 32 5190+ 8 15 23Total 182 625 807Source: Access Economics calculations

8.4.2.2 Avoided Partial Sight And BlindnessA significant benefit from an educational campaign is the avoided reduction in partial sight and blindness that would have otherwise occurred if individuals had not accessed services as a result of an educational campaign.

For those who have undetected and irreversible mild sight loss, it was assumed a campaign would stop the partial sight progressing to moderate before it is detected. Hence the benefit is the avoided reduction in the quality of life for the rest of a person’s life. Similarly, it was assumed that for those who have undetected and irreversible moderate sight loss, a campaign would stop the partial sight progressing to blindness (severe partial sight) before it is detected. Hence the benefit is the avoided reduction in the quality of life for the rest of the person’s life.

The DALYs reduced from avoiding a further reduction in partial sight were calculated by multiplying the avoided disability (difference in disability weights between mild and moderate, and moderate and severe) by the prevalence of MEGs with irreversible mild and moderate sight loss who are expected to change their behaviour as a result of an educational campaign (9 per cent).

The total reduction in DALYs was estimated to be around 4,227 from avoiding a reduction in visual acuity from mild to moderate and 2,958 from avoiding a reduction in visual acuity from moderate to severe, giving a total of 7,185 DALYs, which is shown in Table 8-22.

Table 8-22: Estimated Reduction In DALYs From Avoiding Further Reduction In Partial Sight In MEGs

AgeAMDMild

AMDMod

CataractsMild

CataractsMod

DRMild

DRMod

0- 4 - - - - - -5- 9 - - - - - -0-14 - - P - - - -15-19 - - - - - -20-24 - - - - 3 425-29 - - - - 7 1230-34 - - - - 21 3635-39 - - - - 45 7840-44 - - 13 - 57 9945-49 - - 11 - 40 7050-54 - - 8 52 67 11655-59 3 - 7 47 33 5860-64 2 - 3 21 26 4565-69 4 10 3 21 23 4070-74 3 9 1 16 10 1775-79 0 4 0 2 1 280-84 1 10 1 6 2 485-89 2 12 1 7 2 390+ 2 8 1 3 0 0Total 18 53 50 175 336 583

AgeGlaucoma

MildGlaucoma

ModRE

MildRE

ModOtherMild

OtherMod

0- 4 - - 92 52 22 115- 9 - - 107 60 26 130-14 - - 126 71 31 1515-19 - - 170 Q 96 42 2120-24 - - 228 128 56 2825-29 - - 223 126 55 2730-34 - - 149 84 39 2035-39 - - 120 68 36 1840-44 155 121 258 145 90 4445-49 108 85 265 149 83 4150-54 84 66 175 98 64 3255-59 44 34 120 68 45 2260-64 68 5 146 82 53 2665-69 78 9 124 70 52 2670-74 44 5 65 37 29 1575-79 8 5 14 8 4 680-84 19 18 27 15 9 1585-89 17 15 25 14 9 1690+ 5 5 12 7 4 8Total 630 368 2,444 1,377 748 402

AgeALL VI

MildAll VIMod

0- 4 115 635- 9 133 730-14 156 8615-19 211 11620-24 286 16025-29 285 16530-34 210 14035-39 201 16340-44 573 41045-49 507 34550-54 397 36455-59 253 22960-64 298 17965-69 285 17670-74 152 9775-79 27 2780-84 59 6985-89 55 6790+ 24 31Total 4,227 2,958Note: Mild = <6/12 to 6/18 Mod = <6/18 to 6/60Source: Access Economics calculations

8.4.2.3 Total Benefits From A Campaign Directed At MEGsTotal benefits from a campaign directed at MEGs includes DALYs reduced through corrected vision and DALYs reduced through avoided progression in partial sight. In total this was estimated to be 7,992 DALYs.

8.4.3 Costs Of Improving Partial Sight And Blindness In MEGsThe costs of an educational program to improve visual acuity in MEGs includes the cost of the program itself (estimated in Section 8.4), costs of the initial sight tests, costs associated with treatment from either correcting vision or halting further progression of a condition, and the deadweight loss generated from having to raise additional taxation revenue to provide additional eye care services.

8.4.3.1 Costs Of Initial Sight TestThe Department of Health sets the NHS eye test fee for England, Wales and Northern Ireland for every year. Domiciliary visits have a separate fee for the

first and second patients seen at one visit, and another fee for the third and subsequent patients. In 2008, the fee for a standard NHS sight test was £19.80 (DoH, 2008), which is the cost of a sight test used in this case study.

Based on the proportion of the target population that will take an eye test as a result of the campaign (9 per cent or 4,983 people), the total cost of additional eye sight tests as a result of a public health campaign is estimated at around £99,000 in 2008 prices.

8.4.3.2 Costs Of Additional TreatmentOf the 4,983 additional people who take an eye test, it is estimated that all will undergo some form of further treatment. The treatment will be specific to their condition and will depend on whether the partial sight is correctable, or whether further reduction in visual acuity can be avoided.

Estimated costs of treatment for each condition are outlined in detail within Section 8.3.4.2. In summary, they are: AMD - £4,199 per person; Cataract - £4,591 per person; Glaucoma - £577 per person; Diabetic retinopathy - £2,120 per person; Refractive error - £641 per person; and Other - £2,426 per person

Multiplying the detected number of cases that are remediable and detected number of cases where treatment would stop conditions from progressing, the total cost of treatment was estimated at £8.13 million in 2008 prices. This is shown in Table 8-23, where costs are broken down by condition type.

Table 8-23: Estimated Cost Of Additional Treatment To MEGs

ConditionRemediable

casesno

Non remediable

but treatable

casesno

Cost of correction£million

R Cost of

stopping further

sight loss£million

Total cost

£million

AMD 0 193 - 0.81 0.81Cataracts 626 243 2.87 1.12 3.99DR 0 194 - 0.41 0.41Glaucoma 0 361 - 0.21 0.21RE 2199 855 1.41 0.55 1.96Other 0 311 - 0.75 0.75Total 2,825 2,158 4.28 3.85 8.13Source: Cruess et al (2006), Guide Dogs (2003), NHS (2004), Traverso et al (2005), Access Economics calculations

8.4.3.3 Deadweight LossAs additional tax revenue would need to be raised to fund additional sight tests and treatment there will be an associated deadweight loss that represents a cost to the economy. Using a marginal cost of public funds to the economy of £0.12 (Kleven and Kreiner, 2006), the estimated deadweight loss is around £0.99 million.

8.4.3.4 Total Cost Of The CampaignThe total cost of the campaign includes the cost of media and the road show, the cost of eye test, treatment to correct partial sight, and treatment to stop a condition progressing further. Total cost was estimated at around £9.8 million, as shown in Table 8-24.

Table 8-24: Total Cost Of A Campaign To Increase MEG Eye Care Access

Type of cost S £ millionMedia 0.31Roadshow 0.30Eye tests T 0.10Treatment (corrected vision) 4.28Treatment (stop condition) 3.85Deadweight loss 0.99Total 9.83

Source: Access Economics’ calculations

8.4.4 Net Benefits From A CampaignBenefits of an educational program are the avoided costs associated with undetected partial sight and blindness, and amount to a reduction of 7,992 DALYs. Given the total costs it is expected that a program to increase information and knowledge of eye conditions and eye services would result in a cost effectiveness ratio of £1,230 per DALY avoided.

8.4.5 Sensitivity AnalysisAs the results in the above economic evaluation rely on a number of data assumptions a sensitivity analysis using Monte Carlo simulation was undertaken. Each input variable had a triangular distribution placed around the assumption used in the economic evaluation, with a minimum and maximum chosen based on a hypothetical range of possible values for each variable. The inputs varied their means, and their minimum and maximum values are shown in Table 8-25.


Variable U Minimum

V Mean

W Maximum

Target population who see the campaign (%) 0.50 0.64 0.78Individuals who act on the campaign, given they have seen the campaign material (%) 0.05 0.14 0.23

Conditions undetected – AMD (%) 43 86 95Conditions undetected – Cataract (%) 44 88 97Conditions undetected – DR (%) 44 88 97Conditions undetected – Glaucoma (%) 37 74 83Conditions undetected – RE (%) 48 96 98Conditions undetected – Other (%) 44 88 97Time partial sight is undetected (years) 2 5 8Conditions that are remediable (%) 60 72 84Cost of sight test (£ per exam) 15.00 19.80 24.60Cost of treatment – AMD (£ per person) 3779 4,199 4619Cost of treatment – Cataract (£ per person) 4132 4,591 5050Cost of treatment – DR (£ per person) 519 577 635Cost of treatment – Glaucoma (£ per person) 1908 2,120 2332Cost of treatment – RE (£ per person) 577 641 705Cost of treatment – Other (£ per person) 2183 2,426 2669Cost of campaign (£ per person targeted) 0.04 0.058 0.076

The distribution of the cost effectiveness ratio as a result of the Monte Carlo simulation was plotted. The minimum cost effectiveness ratio was estimated as £796 per DALY avoided while the maximum was estimated as £1,960 per DALY avoided. The mean cost effectiveness was estimated as £1,275 per DALY avoided. The 90 per cent confidence interval is between £1,032 per DALY avoided and £1,559 per DALY avoided.

9. ConclusionsAccess Economics (Australia) was commissioned by the Royal National Institute of Blind People (RNIB) to estimate the economic impact of partial sight and blindness in the UK adult population, including the direct and indirect costs of partial sight and blindness, and the burden of partial sight and blindness on health. In addition, Access Economics was asked to undertake an international comparison (Australia, US, Japan, and Canada) and several cost effectiveness analyses on strategic interventions that are expected to prevent and ameliorate the impact of sight loss in the UK adult population.

Partial sight and blindness is defined in this study as best-corrected visual acuity of <6/12 or a visual field of <20° or homonymous hemainopia in the better-seeing eye. It thus comprises blindness and sight loss. Six conditions that lead to partial sight and blindness investigated in this study, including: age-related macular degeneration (AMD); cataract; diabetic retinopathy; glaucoma; refractive error; and other causes of partial sight and blindness.

The prevalence of partial sight and blindness in 2008, and prevalence projections to 2050, were estimated using prevalence rates derived from the literature and population estimates calculated by Access Economics. In total, it was estimated that there are around 1,796,990 people in the UK who had partial sight and blindness in 2008, the majority of these being adults 50 years and older. Of those with partial sight and blindness: 1,138,792 (63 per cent) people had mild sight loss; 440,268 (24.5 per cent) people had moderate sight loss; and 217,930 (12.1 per cent) people had severe sight loss (blindness).

It is projected that by 2050 there will be approximately 3.99 million people with partial sight and blindness in the UK, which is an increase of around 122 per cent from 2008 estimates.

The large prevalence of partial sight and blindness means sight loss in the UK adult population imposes a significant cost on public funds, private expenditure, and health. The total cost of partial sight and blindness was estimated as £22.0 billion in 2008. This study did not estimate the expected large, and additional costs, associated with partial sight and blindness for children (less than 18 years of age) so the total cost is expected to be underestimated.

Direct health care system costs amount to £2.14 billion and indirect costs amount to £4.34 billion in 2008. In addition, the loss of healthy life and the loss of life due to premature death associated with partial sight and blindness were estimated to have reduced the total capital stock of health by £15.51 billion in 2008.

The majority of direct health care system costs are attributable to hospital recurrent expenditure and non-admitted expenditure, totalling around £1.1 billion (or 51 per cent). Further significant cost items include general ophthalmic services (£484 million or 23 per cent), residential and community care services (£305 million or 14 per cent), and prescribing expenditure (£158 million or 7 per cent). Other costs include capital and administration costs relating to partial sight and blindness and research and development.

The largest indirect costs component is attributable to informal care costs, totalling around £2.03 billion (or 47 per cent) in 2008. Another significant indirect cost is associated with lower unemployment in those with sight loss, which was estimated as £1.63 billion (or 38 per cent). Other indirect costs associated with partial sight and blindness in 2008 include expenditure on devices and modifications (£336 million or 8 per cent), inefficiency resulting from increased tax revenue to fund public expenditure known as deadweight loss (£269 million or 6 per cent), absenteeism and premature mortality.

However, the largest cost associated with partial sight and blindness is the loss in the stock of health capital due to a reduced quality of life and premature mortality. It was estimated that a reduction in the quality of life due to partial sight and blindness reduced the total stock of health capital by £14.53 billion in 2008, and a reduction in health due to premature death resulted in a reduced stock of health capital by £978 million.

Health care system costs and indirect costs were projected to 2013 using prevalence projections. In summary, costs are expected to grow by an annual average growth rate of 3.95 per cent over the next five years, totalling around 21.4 per cent. It is projected that in 2013 direct health care system costs will be £2.60 billion and indirect costs will be £5.27 billion, totalling around £7.88 billion.

In addition to estimating the economic cost of partial sight and blindness in the UK adult population, four hypothetical eye care interventions were evaluated to estimate their potential cost effectiveness. These focused on four areas that have been identified as most relevant for current policy, and include: promote the prevention of eye injuries; improve access to integrated low vision and rehabilitation services; increase regular eye tests for the older population (?60 years); and increase access to eye care services for MEGs.

All four interventions consist of an educational program to increase knowledge of eye conditions and eye care services, although each educational campaign was assumed to be targeted at different populations. Within all program interventions three distinct areas were investigated. These include inputs into the intervention and their associated costs (for example the cost associated with developing and implementing a new program), outputs from the intervention (for example, an increase in access to new services), the outcomes associated with the outputs (for example, a reduced risk of partial sight and blindness).

The results show that the most effective campaign is expected to be one that focuses on MEGs. This is because their access to eye care services is lower than the average population and their undetected eye conditions are more likely to be severe. It was estimated that an educational campaign using media and an educational road show to ten locations heavily populated with MEGs throughout the UK could result in a cost effectiveness ratio of £1,230 per DALY avoided (90 per cent confidence interval of £1,032 per DALY avoided to £1,559 per DALY avoided)

Results of the other three economic evaluations show there are many gains to be made in investing in the promotion of eye care services. In summary the results indicated the following.

A cost effectiveness ratio of £24,200 per DALY avoided for a campaign that targets older people (?60 years) to take up regular eye examinations

(90 per cent confidence interval of £17,000 per DALY avoided to £41,200 per DALY avoided).

A cost effectiveness ratio of £100,857 per DALY avoided for a campaign that encourages those with recognised partial sight and blindness to use low vision services (90 per cent confidence interval of £73,900 per DALY avoided to £152,900 per DALY avoided).

A benefit/cost ratio of 1.62 for a campaign that promotes the use of eye protection to avoid eye injuries (90 per cent confidence interval of1.32 to 2.25).

10. Appendix ATable A-1: HRG Mapping To Eye Condition Within Reference Cost Data

HRG V.4 Description X Assigned condition

BZ01Z Enhanced cataract surgery CATBZ02Z Phacoemulsification cataract extraction and lens

implantCAT

BZ03Z Non-phacoemulsification cataract surgery CATBZ04Z Lens capsulotomy CATBZ05Z Oculoplastics Category 3 OTHBZ06A Oculoplastics Category 2: 19 years and over OTHBZ06B Oculoplastics Category 2: 18 years and under OTHBZ07A Oculoplastics Category 1: 19 years and over OTHBZ07B Oculoplastics Category 1: 18 years and under OTHBZ08A Orbits / lacrimal Category 3: 19 years and over OTHBZ08B Orbits / lacrimal Category 3: 18 years and under OTHBZ09A Orbits / lacrimal Category 2: 19 years and over OTHBZ09B Orbits / lacrimal Category 2: 18 years and under OTHBZ10A Orbits / lacrimal Category 1: 19 years and over OTHBZ10B Orbits / lacrimal Category 1: 18 years and under OTHBZ11Z Cornea / Sclera - category 3 REBZ12Z Cornea / Sclera - category 2 REBZ13Z Cornea / Sclera - category 1 REBZ14A Ocular Motility Category 3: 19 years and over OTHBZ14B Ocular Motility Category 3: 18 years and under OTHBZ15A Ocular Motility Category 2: 19 years and over OTHBZ15B Ocular Motility Category 2: 18 years and under OTHBZ16A Ocular Motility Category 1: 19 years and over OTHBZ16B Ocular Motility Category 1: 18 years and under OTHBZ17Z Glaucoma - category 3 GLCBZ18Z Glaucoma - category 2 GLCBZ19Z Glaucoma - category 1 GLCBZ20Z Vitreous Retinal Procedures - category 4 DRTBZ21Z Vitreous Retinal Procedures - category 3 DRTBZ22Z Vitreous Retinal Procedures - category 2 DRTBZ23Z Vitreous Retinal Procedures - category 1 DRTContinued next page

Table A-1: HRG Mapping To Eye Condition Within Reference Cost Data

HRG V.4 Description Y Assigned condition

BZ24A Non-Surgical Ophthalmology with length of stay 2 days or more and age 19 years and over

AMD

BZ24B Non-Surgical Ophthalmology with length of stay 2 days or more and age 18 years and under

AMD

BZ24C Non-Surgical Ophthalmology with length of stay 1 day or less and age 19 years and over

AMD

BZ24D Non-Surgical Ophthalmology with length of stay 1 day or less and age 18 years and under

AMD

Note: CAT = Cataract, RE = Refractive error, GLC = Glaucoma, DRT = Diabetic retinopathy, AMD = Age-related macular degeneration, OTH = Other.

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Future Sight Loss UK 1 - Full Report - RNIB · Web viewThe economic impact of partial sight and blindness in the UK adult population Contents Executive summary 1. Background 1.1 Definitions

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