WHC (2007) 029

WELSH HEALTHCIRCULAR

Issue Date: 23 March 2007 Status: Direction

Title: CVI(W) Form: Identification and notification of sight loss - changes to registering patients as severely sight impaired (blind) or sight impaired (partially sighted).

For Action by: See paragraph(s) : 8

Action required See paragraph(s) : 8

For Information to: See attached list

Sender: John Sweeney, Community, Primary Care and Health Services Policy Directorate, Health and Social Care Department, Cathays Park, Welsh Assembly Government

Welsh Assembly contact(s) : Welsh Assembly Government contact: Gerry Lynch, Community Primary Care and Health Services Policy Directorate – (029) 20 823033

Enclosure(s): • Sample Explanatory Notes for Consultant Ophthalmologists and Hospital

Eye Clinic Staff at Appendix 1 • Sample CVI(W) form in English at Appendix 2 • Sample Letter of Vision Impairment (LVI) at Appendix 3 • Sample Referral of Vision Impaired Patient (RVI) at Appendix 4

2

Distribution List

3

Chief Executives NHS Trusts Chief Executives Local Health Boards Chief Executives Local Authorities Directors of Social Services Local Authorities Director NHS Confederation in Wales Chief Officer Association of Welsh Community Health Local

Authorities Chief Officers Community Health Local Authorities Director Welsh Local Government Association Dean University of Wales, Bangor Chief Executive Commission for Racial Equality Chief Executive NLIAH Secretary British Dental Association in Wales Postgraduate Dean University of Wales College of Medicine Director information services University of Wales College of Medicine Secretary British Medical Association (Wales) Regional Head of Health UNISON Board Secretary Royal College of Nursing (Wales) Welsh Council Representative

British Dietetic Association

Wales Secretary British Orthoptic Society Wales Secretary AMICUS MSF Regional Secretary The GMB Regional Secretary Transport & General Workers Union Chair Community Pharmacy Wales Chair Royal College of General Practitioners General Secretary Wales TUC Assistant Director Chartered Society of Physiotherapists Officer for Wales Society of Radiographers IR Officer Society of Chiropodists and Podiatrists Regional Secretary Union of Construction Allied Trades and

Technicians Board Secretary for Wales Royal College of Midwives Officer for Wales AMICUS Electrical & Engineering Staff

Association Regional Secretary AMICUS Amalgamated Electrical and

Engineering Union Welsh Executive Royal Pharmaceutical Society of Great Britain Information Officer Wales Council for Voluntary Action National Member for Wales AMICUS - Guild of Health Care Pharmacists Business manager Institute of Health Care Management Welsh

Division Chief Executive Association of Optometrists President College of Optometrists President Royal College of Opthalmologists Director General Audit Commission (Wales) Director Business Service Centre Patch Managers Business Service Centres across Wales (6

copies each) Secretariat Statutory Committees Regional Directors NHS Wales Regional Offices Chief Executive Health Commission Wales (Specialist Services) Chief Executive Health Professions Wales Librarian National Public Health Service Chief Executive Welsh Language Board / Bwrdd yr Iaith

Gymraeg Librarian Health Promotion Library National Director National Public Health Service Director Public Health Laboratory Service in Wales Chairman Optometry Wales Professional Secretary Optometry Wales Director Disability Wales Martyn Rees Directorate of Performance & Operations Michael O’Leary Leonard Cheshire Foundation. Director Wales Council for the Blind Director RNIB Cymru Director Sense Cymru Director Disability Wales Director North Wales Society for the Blind Director Gwent Association for the Blind Director Cardiff Institute for the Blind Catey Bunce Moorfields Eye Hospital CVC Facilitators LHBs/Local Authorities Eleri Mills, Senior Lecturer NEWI Postal Point 20, Plas Coch Campus, Mold

Road Wrexham LL11 2AW

4

Dear Colleague:

Summary 1. The purpose of this circular is to provide guidance for the launch of the new Certificate of Vision Impairment (CVI(W)) and accompanying Letter of Vision Impairment (LVI) and Referral of Vision Impairment (RVI). The CVI(W) replaces form BD8 and formally certifies someone as partially sighted or as blind so that the Local Authority can register him or her. Its second purpose is to record a standard range of

iagnostic and other data that may be used for epidemiological analysis. d Explanatory Notes for Consultant Ophthalmologists and Hospital Eye Service Staff are at Appendix 1. 2. The application form to the certificate is available to Health Professionals at

http://howis.wales.nhs.uk/cviwales in both English language and Welsh language formats and replaces form BD8 (1990) from 9th April 2007. A sample copy of the CVI(W) in English is at Appendix 2.

3. The development of two standard referral documents is designed to provide

additional opportunities to refer people with failing sight for a social services assessment in advance of CVI(W) being completed. These documents have been now been customised and translated for use in Wales. The:

• Letter of Vision Impairment (LVI) (Appendix 3) is for high street

optometrists to enable self-referal, • Referral of Vision Impaired Patient (RVI) (Appendix 4) is for Hospital Eye

Service departments/clinics to use before a CVI(W) is appropriate.

The aim is to reduce delays in referral, for example having to wait for a condition to stabilise before certification. The templates for the two documents can be downloaded from the following websites:

• LVI is available at http: http://www.eyecarewales.nhs.uk • RVI is available at http://howis.wales.nhs.uk/cviwales

4. All previous Circulars relating to form BD8 (1990) are hereby cancelled from 9th April 2007.

Background 5. The Certificate of Vision Impairment, CVI 2003 (Gateway reference 2115)

replaced the BD8 form in England in 2003. This and associated documents were updated in 2005 following consultation with a wide range of professionals, other government departments and voluntary organisations working in the field of visual impairment in England. The document was re-launched in September 2005 by the Department of Health for use in England. By this stage it was clear that the system was working well in England and continues to be used as an opportunity to improve the integration of health and social care.

5

6. From 9th April 2007 the new CVI(W) form will be the formal notification required by Local Authorities with social services responsibilities to register someone as sight impaired or as severely sight impaired in Wales. Form BD8 should no longer be accepted from 9th April 2007.

Articles describing the background to these changes are at: http://www.sightlossmatters.com

Further information about visual impairment can be found on the following websites:

Royal College of Ophthalmologists http://www.rcophth.ac.uk/College of Optometrists http://www.college-optometrists.org/default.aspVision 2020 http://www.vision2020uk.org.uk/Royal National Institute of the Blind http://www.rnib.org.uk/The Eye Care Wales website http://www.eyecarewales.nhs.uk

Action 8. Chief Executives of Local Health Boards (LHBs), Local Authorities and NHS

Trusts should ensure that health and social care professionals, statutory bodies and voluntary organisations working in the field of visual impairment in Wales are made aware of this circular and arrange for relevant stakeholders in their areas to receive a copy of this circular where appropriate, and ensure that new arrangements are put in place from 9th April 2007.

Yours sincerely

John Sweeney Pennaeth y Gyfarwyddiaeth Polisi Iechyd Cymunedol, Gofal a Gwasanaethau Iechyd

6

Head of Community Primary Care & Health Services Policy Directorate

APPENDIX 1

1

Certificate of Vision Impairment (Wales) CVI(W): Explanatory Notes for Consultant Ophthalmologists and

Hospital Eye Service Staff S

tatus of the form

1. The form Certificate of Vision Impairment (Wales) (CVI(W)) will replace form BD8 (1990)in Wales from 9th April 2007.

2. The new form is based on CVI 2005, which resulted from extensive consultation

with amongst others service users; academics; the Association of Directors of Social Services (ADSS); Department of Culture, Media and Sport; Department of Work and Pensions; Inland Revenue; National Assembly for Wales; Northern Ireland; Optometrists; RNIB and various other voluntary organisations; Royal College of Ophthalmologists; Scottish Executive; social workers and specialist rehabilitation workers.

3. This revision has also included the development of two standard referral

documents to provide additional opportunities to refer people with failing sight for a social services assessment in advance of CVI(W) being completed. The:

Letter of Vision Impairment (LVI) is for high street optometrists to enable

people to self-refer, and the Referral of Vision Impaired Patient (RVI) is for Hospital Eye Service

departments/clinics to use before a CVI(W) is appropriate.

The aim is to reduce delays in referral, for example having to wait for a condition to stabilise before certification. The templates for the two documents can be downloaded from the same website as these notes: http://howis.wales.nhs.uk/cviwales The LVI is also available at : http://www.eyecarewales.nhs.uk

4. All previous Circulars relating to the use of form BD8 (1990) in Wales are hereby

cancelled from 9th April 2007. P

urpose of the form 5. The CVI(W) performs the same function as BD8. That is, it formally certifies

someone as partially sighted or as blind (now using the preferred terminology ‘sight impaired’ or ‘severely sight impaired’, respectively) so that the Local Authority can register him or her. Registration is voluntary, and access to various, or to some, benefits and social services is not dependent on registration. If the person is not known to social services as someone with needs arising from their visual impairment, registration also acts as a referral for a social care assessment.

6. There is a secondary purpose to the form, which is to record a standard range of

diagnostic and other data that may be used for epidemiological analysis (see below). The other recipients of the CVI(W) form will also be able to see this information.

APPENDIX 1

2

Payment of fees 7. For a consultant ophthalmologist employed on the 2003 consultant contract, work

included in their job plan and scheduled into programmed activities, unless otherwise agreed with their employer, should not attract an additional fee. Consultant ophthalmologists who have remained on the ‘old’ consultant contract may continue to make requests for the payment of fees. For information on the fees payable please see the relevant pay circulars at:

http://www.nhsemployers.org/pay-conditions/index.cfm

8. In addition, a fee may only be paid if:

a special examination is necessary; necessary information cannot be readily given from knowledge of the case; an appreciable amount of work is involved extracting information from case

notes; certification after 9th April 2007 is recorded on form CVI(W).

9. Local Authorities should not be involved in this process as payments are the

responsibility of the local health service. Managing the form and associated referral letter 10. Neither the form CVI(W) nor the eye clinic referral letter (RVI) will be available as

hard-copy to purchase. The template for forms CVI(W), LVI and RVI can be downloaded as needed from the following HOWIS Website

http://howis.wales.nhs.uk/cviwales

The LVI is also available at : http://www.eyecarewales.nhs.uk

11. The documents should be opened as ‘read only’ copies, saved with a local file

name, and tailored with the hospital’s logo and/or the clinic contact details. 12. Hospital Eye Service departments/clinics that do not have internet access should

make arrangements to obtain a copy of the template file through their IT department or library service.

13. An eye service that wishes to computer-automate the process of completing the

form may do so. This is provided all the fields agreed for the CVI(W) are used and the printed version matches the pages of the CVI(W) template in all respects. The associated information for patients contained in the sheet ‘About this Certificate’ and the ‘Information for driving licence holders’ does not have to be reproduced in the suggested format each time, but should be made available to a patient in whichever format is most accessible for him or her.

14. It is expected that services will keep a copy of the completed form, signed by the

consultant and the patient, for their records. They will then send the form to the relevant Local Authority/LHB, the GP and the patient. This can be done

APPENDIX 1

3

electronically if appropriate and in line with data sharing protocols. If Social Services Departments are satisfied that a hard copy with both signatures exists in the hospital notes, electronic versions can be accepted for registration. However, hospitals may wish to produce an electronic signature for their consultants. A hard copy of the form will also need to be sent for epidemiological analysis by Moorfields Eye Hospital (address under paragraph 17).

15. If you are unable to e-mail the copies to the relevant Local Authority/LHB, the GP

and the patient, you will need to send them hard copies. It is essential that the copy issued to the patient be of the highest quality reproduction.

16. Hospital services will need to be clear about which Local Authority or agency

covers the place in which the patient lives so that the CVI(W) can be sent to the correct place. Local Authorities who receive an RVI letter and/or CVI(W) form in error should urgently forward it to the service in the correct locality. This is no different from the previous arrangements with the form BD8.

E pidemiological data 17. Since 1st September 2005 the collection and analysis of the anonymised

epidemiological data in England and Wales has been undertaken for the Royal College of Ophthalmologists by Moorfields Eye Hospital. From 9th April 2007 Hospital Eye Service departments/clinics should send a stapled copy of pages 1- 6 of the CVI(W) form to:

Royal College of Ophthalmologists, c/o Certifications Office Empire House 133-144 City Road London EC1V 2QN

18. Hospital Eye Service departments/clinics may wish to send packages of forms

monthly or quarterly, depending on usage. Please ensure the package is clearly marked with the year to which the forms relate.

C ompleting the form 19. General: Although there are some technical elements on the CVI(W), some

information on the form and all the information on the RVI describes the person’s situation and is designed to help social services departments determine the priority of the referral. The patient should be actively involved in completing these aspects of the form.

20. Technical: The following paragraphs 21 - 29 can be used to help decide whether

to certify a person as severely sight impaired (blind) or as sight impaired (partially sighted). These are the same as the notes on the front page of the BD8.

21. If there are different causes in either eye, choose the cause in the last eye to

become certifiably visually impaired. If there are different pathologies in the same eye, choose the cause that in your opinion contributes most to visual loss. If it is impossible to choose the main cause, indicate multiple pathologies.

APPENDIX 1

4

Severely sight impaired 22. The National Assistance Act 1948 states that a person can be certified as

severely sight impaired if they are “so blind as to be as to be unable to perform any work for which eye sight is essential” (National Assistance Act Section 64(1)). The test is whether a person cannot do any work for which eyesight is essential, not just his or her normal job or one particular job.

23. Only the condition of the person’s eyesight should be taken into account, other

physical or mental condition should be ignored. The main condition to consider is what the person’s visual acuity is. Visual acuity is the best direct vision that can be obtained, with appropriate spectacle correction if necessary, with each eye separately, or with both eyes together if a person has both. Visual acuity is tested to Snellen’s type and is also defined in Logmar.

Who should be certified severely sight impaired? People can be classified into three groups: 24. Group 1: People who are below 3/60 Snellen

Certify as severely sight impaired: most people who have visual acuity below 3/60 Snellen.

Do not certify as severely sight impaired: people who have visual acuity of 1/18 Snellen unless they also have considerable restriction of visual field. In many cases it is better to test the person’s vision at one metre. 1/18 Snellen indicates a slightly better acuity than 3/60 Snellen. However, it may be better to specify 1/18 Snellen because the standard test types provide a line of letters which a person who has a full acuity should read at 18 metres.

25. Group 2: People who are 3/60 but below 6/60 Snellen

Certify as severely sight impaired: people who have a very contracted field of vision. Do not certify as severely sight impaired: people who have a visual defect for a long time and who do not have a very contracted field of vision. For example, people who have congenital nystagmus, albinism, myopia and other conditions like these.

26. Group 3: People who are 6/60 Snellen or above

Certify as severely sight impaired: people in this group who have a contracted field of vision especially if the contraction is in the lower part of the field. Do not certify as severely sight impaired: people who are suffering from homonymous or bitemporal hemianopia who still have central visual acuity 6/18 Snellen or better.

APPENDIX 1

5

Other points to consider 27. These points are important because it is more likely that you will certify a person

in the following circumstances: How recently the person’s eyesight has failed? A person whose eyesight has

failed recently may find it more difficult to adapt than a person with same visual acuity whose eyesight failed a long time ago. This applies particularly to people who are in group 2 and 3 above.

How old the person was when their eyesight failed? An older person whose eyesight has failed recently may find it more difficult to adapt than a younger person with the same defect. This applies particularly to people in group 2 above.

Sight impaired 28. There is no legal definition of sight impairment. The guidelines are that a person

can be certified as sight impaired if they are ‘substantially and permanently handicapped by defective vision caused by congenital defect or illness or injury’.

29. People who are certified as sight impaired are entitled to the same help from their local social services as those who are certified as severely sight impaired. However, they may not be eligible for certain social security benefits and tax concessions for people who are certified as severely sight impaired.

30. As a general guide, certify as sight impaired, people who have visual acuity of:

3/60 to 6/60 Snellen with full field. up to 6/24 Snellen with moderate contraction of the field, opacities in media or

aphakia 6/18 Snellen or even better if they have a gross defect, for example

hemianopia, or if there is a marked contraction of the visual field, for example in retinitis pigmentosa or glaucoma.

Diagnosis not covered (including ICD-10 code) 31. The International Classification of Diseases (ICD)-10 was endorsed by the forty-

third World Health Assembly in May 1990 and came into use in World Health Organization States as from 1994. The ICD has become the international standard diagnostic classification for all general epidemiological and many health management purposes. These include the analysis of the general health situation of population groups and monitoring of the incidence and prevalence of diseases and other health problems in relation to other variables such as the characteristics and circumstances of the individuals affected. More information about ICD-10 is available on the World Health Organization’s website at: http://www.who.int/en

APPENDIX 1

6

Other points to consider 32. Infants and young children who have congenital ocular abnormalities leading

to visual defects should be certified as sight impaired unless they are obviously severely sight impaired.

33. Children aged 4 and over should be certified as severely sight impaired or sight

impaired according to the binocular corrected vision. Transferring and retaining the CVI(W) (W) 34. A copy of the CVI(W) should be forwarded to the patient’s GP and local authority

within five working days of its completion. 35. In accordance with Progress in Sight, the ADSS National Standards (at:

http://www.adss.org.uk/eyes.shtml ), on receipt of the CVI(W) the patient’s social services department (or its agents) should contact the person and arrange for the following:

an assessment of his or her needs their inclusion on the local authority’s register (with the person’s consent) and

provide a standardised registration card 36. The CVI(W) is an important source of information for Local Authority services and

if a person moves to another area, it should be shared with the new local social services. This will avoid the need for re-certification. The social services copy of the form should be kept until transferred to another authority or until there is evidence that the person is deceased.

APPENDIX 2

1

CVI(W) Certificate of Vision Impairment Certificate of a Person as Sight Impaired (partially sighted) or as

Severely Sight Impaired (blind)

Part 1: To be completed by the patient or representative

My specific attention has been drawn to the paragraph entitled ‘Patient Consent’ on page 6 which requires that my express consent is given to the use of my personal information, and to the ‘Information for driving licence holders’. I understand that my Local Authority or Local Health Board will arrange for me to be registered with them if I so wish. Signature Date I am the patient the patient’s representative. My name is (please print) ......................................................................................................................................... To be completed by the consultant ophthalmologist

That this person is sight impaired (partially sighted) I consider (tick one) That this person is severely sight impaired (blind)

Date of examination _____ (dd) ___ (mm) ________ (yyyy) NB: The date of examination is taken as the date from which any concessions are calculated Consultant’s Signature Consultant’s Name

Hospital address

Epidemiological Analysis: please send a copy of this page to the Royal College of Ophthalmologists, c/o certifications office, Empire House, 136-144 City Road, London, EC1V 2QN

APPENDIX 2

2

Copies in confidence to: Local Authority/Local Health Board Patient Patient’s GP Hospital notes Epidemiological analysis

Part 2: to be completed by the consultant ophthalmologist A. Patient’s details Title and Surname

Other names Date of birth

Address Email

NHS Number Daytime Tel. Details of general practitioner Details of local social services / agent Name Address Tel.

Name Address Tel.

B. Visual function Visual acuity (Snellen, LogMAR or functional assessment, e.g. hand movement or finger counting)

Right eye Left eye

Unaided Best corrected Best corrected with both eyes Field of vision (Put an ‘X’ in the box if abnormal) Low vision service (Put an ‘X’ in

the box) Total loss of visual field Has been assessed Extensive loss of visual field (including hemianopia)

To be referred / assessed

Primary loss of peripheral field Primary loss of central field

Not relevant or the patient does not want an assessment

Does sight vary markedly in different light levels? (Put an ‘X’ by Yes or No) Yes No

Epidemiological Analysis, please send a copy of this page to the Royal College of Ophthalmologists, c/o certifications office, Empire House, 136-144 City Road, London, EC1V 2QN

[Hospital eye service to put hospital logo and/or clinic

contact details in here]

APPENDIX 2

3

C. Diagnosis

Where there is more than one cause of vision impairment please circle or asterisk the main cause.

Right eye Left eye

Retina age-related macular degeneration – subretinal neovascularisation

H35.3

age-related macular degeneration – atrophic / geographic macular atrophy H35.3

diabetic retinopathy E10.3 – E14.3 H36.0

diabetic maculopathy H36.0A hereditary retinal dystrophy H35.5 retinal vascular occlusions H34. other retinal : please specify Glaucoma primary open angle H40.1 primary angle closure H40.2 Secondary H40.5

other glaucoma : please specify

Globe degenerative myopia H44.2 Neurological optic atrophy H47.2

visual cortex disorder H47.6 cerebrovascular disease Choroid chorioretinitis H30.9 choroidal degeneration H31.1 Lens cataract (excludes congenital) H25.9 Cornea corneal scars and opacities H17. Keratitis H16. Paediatric retinopathy of prematurity H35.1 congenital CNS malformations Q00-Q07 congenital eye malformations Q10-Q15

congenital: please specify syndrome or nature of the malformation

Neoplasia Eye C69. brain & CNS C71-72

Male Female Year of birth Postcode (first half)

APPENDIX 2

4

other neoplasia: please specify

Diagnosis not covered in any of the above – please specify, including ICD10 code (where known)

Please note that this is not intended to be a comprehensive list of all possible diagnoses. It does include all but the rare causes of reduced vision abstracted from the 2001 BD8 part 5 returns. The codes above are ICD10. Epidemiological Analysis: please send a copy of this page to the Royal College of Ophthalmologists, c/o certifications office, Empire House, 136-144 City Road, London,

EC1V 2QN

APPENDIX 2

5

Part 3: to be completed by eye clinic staff in consultation with the patient D. Other relevant factors about the patient (Mark all appropriate boxes) Yes Does the patient live alone? Does the patient also have a hearing impairment? Does the patient have poor physical mobility? Does the patient have any other medical conditions that may be relevant? Please specify

Are there any concerns about how the sight problem or the prospect of registration is affecting the patient emotionally? Please make a note of the concerns here:

Would the patient benefit from a discussion with a rehabilitation worker about practical matters such as mobility?

Would the patient benefit from a discussion with a rehabilitation worker about practical matters such as daily living skills?

Would the patient benefit from a discussion with a rehabilitation worker about practical matters such as employment?

In the case of a child, would the parent/s or guardian/s welcome guidance about child development, schooling, social implications or parenting?

Is the patient: Retired Employed Unemployed Child

In the view of clinic staff these factors require contact with the patient (mark the appropriate box): Immediately (i.e. potential risk factors present) Within the next 2 weeks (in line with Association of Directors of Social Services’

national standards) As soon as possible Epidemiological Analysis: please send a copy of this page to the Royal College of Ophthalmologists, c/o certifications office, Empire House, 136-144 City Road, London, EC1V 2QN

APPENDIX 2

6

E. Ethnic origin (This information is needed for service and epidemiological monitoring) a) White c) Asian or Asian British British Indian English Pakistani Scottish Bangladeshi Welsh Other Asian Irish Other white European d) Black or Black British Other White Caribbean African Other Black b) Mixed White and Black Caribbean e) Other ethnic groups White and Black African Chinese White and Asian Gypsy Traveller Other mixed Any other ethnic group F. Patient format preferences The patient would prefer further information: In large print on tape on computer disk by email to _____________________@___________________________________ The language the patient prefers to receive information in is ______________________

APPENDIX 2

7

• See the checklist of people to send copies to, at the top of page 2 of this form. The

Local Authority/Local Health Board will be the one which covers the place where the patient lives.

• For epidemiological analysis, please post all 6 pages, including this one to: (This address has been put here for placing in a window envelope)

The Royal College of Ophthalmologists C/o Certifications Office Empire House 136-144 City Road London EC1V 2QN

APPENDIX 2

8

Appendix 2

1

About this Certificate The Certificate of Vision Impairment (CVI(W)) replaces form BD8 (1990). A consultant ophthalmologist may use it to certify that the named patient is eligible to be registered as sight impaired / partially sighted, or as severely sight impaired / blind under the provisions of the National Assistance Act 1948. The patient’s Local Authority with social services responsibilities will arrange with the explicit consent of the patient, for his or her name to be added to the relevant register. It will also carry out an assessment of needs, and provide information about the services and benefits available to people who are sight impaired or blind.

Advice for patients Use of this form does not affect the provision of any medical care. It establishes that your consultant ophthalmologist considers you eligible to be registered. You will not be added to the local register until you have given your specific consent to the Local Authority or Local Health Board. Registration is voluntary, and you can choose to have your name taken off at any time. Choosing not to be registered may affect your entitlement for some statutory financial benefits. Also, registration means that you will be regarded as ‘disabled’ under the Disability Discrimination Act (DDA). If you are registered, your Local Authority or its agent should offer you a card confirming your registration. Your Local Authority has a legal duty to advise you of the range of services available to people with sight problems and to carry out an assessment of your needs, irrespective of whether or not you choose to be registered. If you have any difficulties in relation to these matters, you can obtain independent advice from:

The Citizens Advice Bureau Your local society for visually impaired people, or the RNIB helpline on 08457 66 99 99 (local call rate)

Appendix 2

2

This page is for the patient only

Patient Consent

I consent to the personal and sensitive personal information contained within this form being passed to my Local Authority, General Practitioner and Local Health Board for referral, assessment and registration purposes; in addition:

I acknowledge that my information will be used by the Royal College of Ophthalmologists on behalf of Moorfields Eye Hospital NHS Foundation Trust (MEH), the Department of Health (DH) and the Welsh Assembly Government for epidemiological research and analysis;

understand that the Royal College, MEH, DH and the Welsh Assembly Government have a duty of confidentiality and duties under the Data Protection Act 1998 towards use of my information;

understand that I do not have to consent to my information being used for any of these purposes, and can withdraw my consent at any point

am aware that I will also be given a copy of this form.

Information for driving licence holders In accordance with the advice shown on the driving licence, any driver with impaired vision should inform the DVLA, who will consider each case on an individual basis. The DVLA can be contacted at: Drivers Medical Branch DVLA Swansea SA99 1TU Tel 0870 600 0301 (Monday to Friday 8.15 to 16.30)

APPENDIX 3

1

Form LVI (Letter of Vision Impairment) Optometrist Identification of Patient with Significant Sight

Problems

About the attached letter This letter is to be issued by an optometrist to patients who would benefit by seeking advice and support from the social services department of their Local Authority.

Advice for patients Sending this letter does not affect the provision of any medical care. Your Local Authority has a legal duty to: advise you of the range of services available to people with sight problems carry out an assessment of your needs

If you have any difficulties in relation to these matters, you can obtain independent advice from:

the Citizens Advice Bureau your local society for visually impaired people, or the RNIB helpline on 08457 66 99 99 (local call rate)

If you have a driving licence, please read the important ‘Information for driving licence holders’.

Please note: This page is for the patient only

APPENDIX 3

2

Information for driving licence holders Every driver must be able to read a pre-September 2001 format number plate at 20.5 metres (or a post September 2001 format number plate at 20 metres) in good light. If your sight is affecting your ability to drive or if the eye specialist has advised you that you are not safe to drive, you are required to contact the:

Drivers Medical Branch DVLA Swansea SA99 1TU Tel 0870 600 0301 (Monday to Friday 8.15 to 16.30) The DVLA must be told at once if: you NOW have any physical or mental disability or condition which affects

your fitness as a driver or which might do so IN THE FUTURE (you do not need to tell DVLA if the effect of the disability or the condition is not expected to last more than 3 months).

You come to know IN FUTURE that you have such a disability or condition. Failure to comply is a criminal offence. Drivers who do not meet the vision requirements and who come to the attention of the police may be liable for a fine of up to £1,000.

Please note: This page is for the patient only

APPENDIX 3

1

For the attention of: [Before printing/copying, optometrist to replace this text with the address of the Local Authority/Social Services Department to which the letter will be sent, including the organisation’s website or referral email address according to where the patient lives.] Date: Dear Sirs, I have been advised to contact you because poor eyesight is making daily life difficult. I would like to know about the range of specialist information or help which is available locally from your, or other agencies. My name is: The optometrist who suggested I contact you is: Please contact: me / my friend / relative / representative as follows Name Address Telephone number / Email address Please contact me or my representative first by

Phone Letter Email

I would prefer further information

In large print On computer disk By email On tape

I would prefer information in __________________________ (language)

APPENDIX 3

2

Now tick any of these statements that apply to you

I live alone I have responsibilities as a carer

I have

difficulty getting about arthritis a heart condition other condition(s) – please specify

I am especially concerned about

cooking on my own crossing roads safely becoming isolated feelings of distress coping at work coping at school/college other – please specify

I am

Under 18 Between 18 and 60 Between 61 and 75 Over 75

Yours faithfully, Please return the completed letter to the following address: [Before printing/copying, optometrist to replace this text with the address of the Local Authority/Social Services Department to which the letter will be sent, including the organisation’s website or referral email address according to where the patient lives.]

APPENDIX 4

1

Hospital Eye Service Form RVI (Referral of Vision Impaired Patient)

for Social Needs Assessment

Signatures and declarations Eye clinic staff I have advised the patient of the contents of this letter, including the ‘Notice to driving licence holders’. Signature:

Name:

Position:

Date:

Patient I have seen, or been advised of, the contents of this letter, including the ‘Notice to driving licence holders’. I consent to a copy of this letter being sent to my local authority and my general practitioner. Signature:

Name:

Date:

[Hospital eye service to put hospital logo

and/or clinic contact details in here]

APPENDIX 4

2

To: [Before printing/copying, hospital eye service to replace this text with the address to which the letter will be sent, including the organisation’s website or referral email address according to where the patient lives.] Copies to: Patient Patient’s GP Hospital file Date: Patient’s name: Address: Telephone number: Email address: Date of birth: GP details: I am referring this patient to you with his/her consent. This is to alert you to changes in vision which are now making daily life difficult. I request an assessment of his/her social and support needs. Please also provide details of the range of specialist information or help that is available from you or other agencies.

APPENDIX 4

3

Please tick any of these statements which apply. The patient must consent to this disclosure. The patient lives alone The patient has: poor hearing difficulty getting about arthritis heart conditions In discussion with the patient, we have agreed to alert you to the following information. There are concerns about: practical aspects of daily living cooking unaided getting about safely becoming isolated feelings of distress coping at work coping at school / college responsibilities as a carer for a third party reading other(s) – please specify In my view these concerns require contact with the patient to be made: immediately (i.e. potential risk factors present) within the next two weeks as soon as possible

APPENDIX 4

4

Please contact the patient in the first instance by: phone visit Interpreter / translation required letter email He / she would prefer information in __________________________ (language) The patient would prefer further information to be made accessible by: large print tape computer disk email to: ______________________________ The patient has been given a copy of this referral letter for information The patient understands that they will be contacted by your organisation without further action on their part. Please contact the patient acknowledging receipt of this referral letter, and advise him/her of the anticipated date for assessment (this is in accordance with the Association of Directors of Social Services national standards)

APPENDIX 4

Page 1 of 2

About this letter Hospital Eye Service staff will use this letter (with the consent of the patient) as a referral to request a social needs assessment from the Local Authority. The letter is likely to be used where registration is not currently appropriate, or the patient has declined registration but he or she wishes for advice and information about social, emotional or practical difficulties arising from serious loss of vision. This letter can be used when medical intervention in the future may alter the situation but there are presenting problems in the meantime.

Advice for patients With your permission, the hospital eye service will send this letter to your Local Authority to ask for you to be contacted for information or advice or other help to be offered. Sending it does not affect the provision of any medical care. Your Local Authority has a legal duty to: advise you of the range of services available to people with sight problems carry out an assessment of your needs

If you have any difficulties in relation to these matters, you can obtain independent advice from:

the Citizens Advice Bureau your local society for visually impaired people, or the RNIB helpline on 08457 66 99 99 (local call rate)

Please note: This page is for the patient only

APPENDIX 4

Page 2 of 2

Information for driving licence holders In accordance with the advice shown on the driving licence, any driver with impaired vision should inform the DVLA, who will consider each case on an individual basis. The DVLA can be contacted at: Drivers Medical Branch DVLA Swansea SA99 1TU Tel 0870 600 0301 (Monday to Friday 8.15 to 16.30)

Please note: This page is for the patient only