Guidance

Child vision screening service specification

Updated 5 October 2023

Applies to England

This service specification for the child vision screening programme outlines the service and quality expected by the commissioning body, currently the local authority, for the population for whom it is responsible. It is based on available evidence and current guidance on recommended standards for safe practice. In the event of new guidance, the specification will be reviewed.

The service specification does not supersede any relevant legislative provisions which may apply, for example, the Health and Social Care Act 2008 or the work undertaken by the Care Quality Commission.

Background

Screening for reduced vision in children aged 4 to 5 years is primarily undertaken to detect children with amblyopia, a form of abnormal vision system development. The most common predisposing conditions are strabismus (squint) and refractive error (focusing problems requiring glasses). Early detection and treatment of amblyopia helps avoid permanent visual impairment. This is because treatment takes place while the visual system is in a period of neuroplasticity (growth and change).

Treatment involves training the brain to pay attention to the amblyopic eye(s). This involves correcting contributing refractive error or penalising the ‘good’ eye using patches or drops which defocus vision. These treatments have been shown to result in improved vision.

The UK National Screening Committee (UK NSC) recommendation for child vision screening via local authority provision is available on GOV.UK.

Programme aims and objectives

The primary aim of the child vision screening programme is to identify children aged 4 to 5 years with impaired sight, enabling timely intervention.

The objectives of the child vision screening programme are to:

• identify the eligible population for screening
• offer parents, carers or guardians the opportunity to have their children screened for reduced vision
• ensure fair access for all children
• refer children to diagnostic services as indicated by their screening outcome
• provide information so parents, carers or guardians can make an informed choice whether to accept the offer of screening
• ensure competent staff who participate in recognised ongoing training and development
• deliver a safe, effective service supported by regular and accurate data collection and audit

Expected health outcomes

The direct health outcome is the optimal development of vision for children with amblyopia through prompt access to treatment.

Equality

The provider should be able to demonstrate what systems are in place to ensure fair access to screening and referral to subsequent diagnostic testing. This will include, but is not limited to, how services are designed to ensure that there are no obstacles to access on the grounds of the 9 protected characteristics as defined in the Equality Act 2010.

Local authorities and screening providers

Child vision screening is commissioned by local authorities. It is the local authority responsibility to identify the eligible population for screening in its area. Screening is offered for all children in the academic year (September to August) they turn 5 years old. Screening may be offered on an ‘opt in’ or ‘opt out’ basis (see sections below).

The local authority commissions an orthoptist-led screening service to carry out child vision screening in suitable premises (such as a designated area in a school).

The screening provider supplies parents, carers and guardians with information so they can make a choice about their child having screening.

The screening provider is responsible for providing and maintaining appropriate equipment for the screening tests.

If a child needs further assessment following screening, the screening provider refers them to the appropriate service(s). The provider is responsible for maintaining screening records, and informing parents, carers or guardians of the screening outcome for their child.

To ensure a coordinated and seamless service in a multi-provider environment, the screening programme provider must work to common standards, policies and protocols with providers of other elements of the complete pathway (such as primary care, community, and hospital eye services).

The care pathway

A pathway for child vision screening accompanies this document. It covers the elements described below.

Identification and invitation of the eligible population

The local authority identifies their eligible population of children aged 4 to 5.

Eligible children are all those who turn 4 in the year preceding the beginning of the school year (with the school year running from September to the following August). It is expected that the local authority will make all reasonable efforts to ensure that any eligible children aged 4 to 5 years who move into the area following the start of the school year are identified and offered vision screening.

Children educated at special needs schools have visual assessment using a test appropriate for their developmental stage in line with current Royal College of Ophthalmologists’ guidance.

The provider supplies written information about the child vision screening programme to parents, carers or guardians when screening is offered.

If a child still does not have screening following a second invitation (for any reason), and there is no record of a declined screening invitation, the provider sends a letter to the child’s parent, carer or guardian explaining this. The letter should advise them to seek a sight test at a local optometrist of their choice.

The provider records the screening offer and any subsequent declined offer - decline being a recorded outcome of the screening offer.

Opt-in versus opt-out

The local authority determines whether to provide an opt-in or an opt-out service.

An opt-in service is one where parental acceptance is sought prior to the screening examination. This runs the risk of lower uptake and may miss children who are at multiple disadvantages.

An opt-out service assumes acceptance of the screening offer unless the parents, carers or guardians decline screening. An opt-out service has higher uptake levels than an opt-in service. However, it may risk a child being screened when their parents, carers or guardians might have wished otherwise.

The screening test and communicating the outcome

All children who are screened are tested by an orthoptist-led screening service, using the Keeler Crowded logMAR test. An orthoptist-led service is run by a registered orthoptist or a vision screener with competency confirmed by a registered orthoptist.

Children who have already been prescribed glasses or contact lenses should wear them for the test.

Children unable to complete the screening test due to lack of co-operation (or any other reason) either undergo a second testing attempt or are referred by the provider directly into community or hospital eye services.

The provider should communicate the outcome of the screening test to the child’s parents, carers or guardians.

Referral of children needing further assessment

The provider is responsible for ensuring all children needing further assessment are referred to the appropriate service.

For management of children with a visual acuity in one or both eyes of less than 0.20 logMAR on the Keeler Crowded logMAR test, refer to the Royal College of Ophthalmologists’ diagnostic pathway for details.

Children who are referred have an assessment of ocular motility and binocular function, cycloplegic refraction, and examination of optical media and retina or fundus.

Children unable to complete the screening test (for example due to lack of co-operation) should either have a second testing attempt or be referred directly to a community or hospital eye service. An eye service should consist of professionals who:

• have clinical competencies which are assessed as being up to date on initially taking up their positions within the eye service as childhood eye health examiners
• have access to advice, training and help from the local orthoptist lead or paediatric ophthalmologist
• continue to engage actively with lead orthoptist
• undertake continued professional development

All providers are expected to review and risk assess local pathways and to develop, implement and maintain appropriate risk reduction measures.

Providing the service

Roles and accountabilities through the screening pathway

The service provider is responsible for the provision of a robust pathway. The local authority is responsible for commissioning this service and managing performance of this pathway. The local authority should obtain assurance from the service provider that systems are in place to maintain the quality of the whole screening pathway. This will include, but is not limited to:

• day to day oversight of all aspects of the programme
• prompt and safe onward referral to the appropriate service

Within their organisation, the provider is recommended to have (with appropriate deputies) a:

• local coordinator - the operational lead for the local programme
• clinical lead - a clinician trained in the diagnosis and management of visual function and eye movement disorders, providing support and clinical oversight

Provider responsibilities

The service provider is expected to:

• invite all eligible children for screening
• provide written information to parents, carers or guardians explaining their choice regarding their child’s participation in the screening programme
• conduct vision screening in line with national recommendations
• ensure children are appropriately referred if they need further diagnostic testing
• provide parents, carers or guardians with the outcome of their child’s vision screening test
• fully and accurately document the results of the programme
• work to recommended standards, guidance and policies
• ensure appropriate governance structures are in place
• develop, implement and maintain appropriate risk reduction measures, and report incidents in a timely manner
• continuously ensure quality and safety, including taking part in local quality assurance (QA) processes and implementing and recommended actions
• ensure the screening workforce has access to appropriate training and continuing professional development (CPD) in order to maintain competence

Service model summary

Childhood vision screening should be provided for eligible children aged 4 to 5 by an orthoptist-led service.

See the section on the care pathway above for further information.

Programme co-ordination and oversight

The provider and commissioning body should meet at regular intervals to monitor and review the local screening pathway and outcomes.

Clinical and corporate governance

The provider should:

• ensure that there is appropriate clinical oversight of the programme and have internal governance of the services provided
• regularly monitor and audit the screening programme, and assure the provider organisation’s board of the quality and integrity of the screening programme
• produce an annual report of the screening programme

Governance

The commissioner should:

• be assured that appropriate clinical oversight and governance arrangements are in place
• be assured of the quality and integrity of the programme through the receipt of monitoring and audit information
• receive an annual report from the provider

Cross-organisational working

The screening programme is dependent on effective working relationships (formal and informal) between the screening programme, ophthalmology departments, community orthoptic services, local educational services, optometric services, and primary care professionals, including school nursing or healthy child services, optical practices and GPs. It is essential that the responsible care provider is identifiable at all times, including during and after handover of care.

The provider is expected to fully contribute to ensuring that cross boundary systems are in place to maintain the quality and safety of the entire screening pathway.

Information about child vision screening

At the start of the school year, and at other relevant points throughout the screening pathway, the provider should supply parents, carers or guardians with relevant information. The parent leaflet may provide a useful guide for discussion. Where there are specific communication requirements (for example visual or hearing impairment or where English is not the parent, carer or guardian’s first language), the provider should use appropriate interpretation services.

Data recording and monitoring

The professional undertaking the screening examination is responsible for ensuring that the results and screening outcomes are recorded. They should enter results on an IT system that has demonstrable failsafe mechanisms in place which are monitored and managed.

Results reporting

For children who require further assessment, were absent or were not tested, the provider should explain the outcome to parents, carers or guardians in writing. Where possible, more detailed information should be made available if requested.

Transfer and discharge from care obligations

Children who require further assessment (onward referral), or who are unable to complete the screening test, remain the responsibility of the screening programme provider until an onward referral is accepted by the relevant service provider.

The provider retains care obligations throughout the vision screening care programme unless a formal transfer of care is made to another care provider, and this is accounted for within a failsafe system.

Staffing and training

Providers should have in place one or more named individuals responsible for co-ordinating the programme. These may be the clinical lead or coordinator. Where there is only one named coordinator or clinical lead, the provider should ensure that there are adequate cover arrangements in place.

Providers must arrange orthoptic-led screener training in line with programme requirements or standards as detailed within the available supporting documents.

Providers should ensure that there are sufficient appropriately trained staff to deliver the screening programme in line with national guidance.

It is recommended that online child vision screening (CVS) e-learning is undertaken by screeners on an annual basis (available via elearning for healthcare (elfh)). Providers must allow appropriate CPD in line with programme requirements. This may include relevant study days or completion of e-learning for all professionals involved in the screening pathway.

Premises and equipment

The provider should ensure appropriate equipment is available to deliver the screening service and will have appropriate policies in place for equipment maintenance and replacement. The provider ensures that suitable premises, including appropriate examination areas within schools, are provided for the screening programme. Please see the guidance on undertaking the screening test.

Service standards, risks and quality assurance

Key criteria and standards

Standards for childhood vision screening for children aged 4 to 5 years are in development. Once available, providers should meet the acceptable standards for all stages of the pathway and continuously work towards the achievable programme standards.

Risk assessment of the pathway

Providers should have an internal quality assurance and risk management process that assures the commissioners of their ability to manage the risks of running a screening programme.

The provider and commissioner should agree plans to mitigate risks. This should involve mechanisms to audit implementation, report incidents, ensure staff training and development, and have appropriate links with internal governance arrangements. Support can be sought from the community or hospital eye services and the Screening Quality and Assurance Service (SQAS) in NHS England.

Quality assurance

Providers should participate fully in quality assurance processes, including the provision of:

• minimum data sets as required
• self-assessment questionnaires or tools and associated evidence

Providers should co-operate in undertaking audits and reviews as requested and respond in a timely manner to their recommendations. All providers should operate failsafe systems that can identify, as early as possible, children that may have been missed or where screening results are incomplete. Providers should produce, with agreement of commissioners, an action plan to address areas recommended for improvement.

Commissioners may suspend a service where there is a significant risk of harm to the population.

Service improvement

Where achievable standards are not being met, the provider is expected to identify and agree with the commissioner what changes and improvements will be made over a defined period.

Data and monitoring

Providers should ensure that:

• appropriate systems are in place to run the programme including audit and monitoring functions
• timely and accurate completion of data takes place for all stages of the care pathway; this should be through the use of an IT system that can ensure demonstrable failsafe processes are in place, and these are monitored and managed - use of such a system is mandatory
• there is continuous monitoring and collection of the recommended minimum dataset for the service and that this information and audit data is available to the commissioner