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What are the links between service costs/practice issues and population characteristics: the case of vision screening for amblyopia in four and five year olds

Lavelle-Hill, David M (2014) What are the links between service costs/practice issues and population characteristics: the case of vision screening for amblyopia in four and five year olds. EdD thesis, UCL Institute of Education .

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Abstract

„Health for all Children‟ (Hall and Elliman, 2006), gives clear recommendations regarding the screening of young children for possible visual difficulties, the focus of which is the detection of amblyopia, defined as,„poor vision due to abnormal visual experience early in life‟ (Webber and Wood, 2005). This policy with its recommendation of the screening of all children between the ages of 4 and 5 was found to be delivered in many ways by different Health Authorities up and down the UK. This raises various questions, including: „What are the determinants that drive the approach taken in terms of implementing this policy?‟ There is a large body of literature suggesting a link between deprivation/poverty and increased health issues; (Aber et al., 1997; Bramley and Watkins, 2008; Howard et al., 2001; Scott and Ward, 2005). There is also evidence that there is a link to amblyopia specifically, (Williams et al., 2008). This research has looked at links between three variables relating to vision screening for amblyopia in four and five year olds; service costs/funding, practice issues and population characteristics. With regard to the last it looked specifically at levels of deprivation as measured by Indices of Multiple Deprivation, or IMD scores(Noble et al., 2008). IMDscores are a useful way of capturing levels of deprivation in a particular area in that as well as providing an overall „score‟ for deprivation, it is possible to see how this score has been made up from various indicators relating to different aspects of an area. The rationale behind this approach is that where several aspects of an area can be described as involving deprivation, these aspects combine and exacerbate each other producing an effect that is greater than the sum of its parts. This „exacerbation‟ is taken into account in the formula for calculating the overall score. In order to obtain information about cost and practice issues, a questionnaire was issued as a Freedom of Information (FOI) request to each of the 152 Primary Care Trusts (PCTs) which made up the map of service delivery in England at the time of the request. Use of an orthoptist (the key medical practitioner regarding eye muscle control/movement and amblyopia) was found to be the most significant factor in terms of practice and also costs for the screening. In particular, use of an orthoptist resulted in a greater and more up to date range of tests being used as well as in a higher cost for the service. Following this collection of quantitative data, a number of follow up questions were pursued by telephone/email/interview. These „case studies‟ were a sub-sample of orthoptists selected on the basis of peculiarities suggested by their returns from PCTs or because they are „key players‟ regarding the work of orthoptists. One determinant regarding the approach to practice/cost is that eye-care services may be taking account of the socio-economic make-up of an area when deciding how/whether to deliver the screening to the 4 and 5 year olds within it. Using all data and therefore including PCTs that don‟t screen, there was a significant relationship between deprivation and use of orthoptists (p<0.05). Orthoptists are more likely to deliver the screening in areas of deprivation. Practice issues were found to follow from the use of orthoptists as opposed to school nurses/school nurse assistants to deliver the screen. Furthermore, there was an increased cost in using orthoptists to deliver the screen. The „mechanism‟ that results in the use of orthoptists to deliver screening in areas of deprivation, is a combination of this group of professionals engaging actively and using their discretion to commission an orthoptist screen, but alsothe use of a notion of „local justice‟ as exhibited at a textural level in the guidelines on clinical commissioning (as well as in the Hall report itself). Whilst policy exists requiring a thorough visual screen for all children including those in areas of deprivation, it is essentially the conscienceof orthoptists (facilitated by their professional discretion) that ensures that children in areas of deprivation are more likely to receive the screenfrom this key medical practitioner in the area of children‟s eye care.

Item Type: Thesis (EdD)
Controlled Keywords: amblyopia, deprivation, street-level bureaucrat, orthoptist, personal construct theory, local justice
Subjects: Departments > Children, Families and Health
Depositing User: Mr Julian Zerfahs
Date Deposited: 11 Apr 2015 14:03
Last Modified: 15 Apr 2015 15:13
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