32-33 - VISION: In our sights

The inverse care law describes how those with the greatest need often have the fewest provisions available to them and this is true both within and between countries. This, and the concept of health equity, are not new phenomena.

The COVID-19 pandemic, however, has brought these to the forefront of attention and has potentially exacerbated these inequities further. Long waiting times and a resurgence in demand for services have only added to the barriers that inhibit individuals from receiving the right treatment at the right time.

According to the World Health Organization, health equity is achieved when everyone can attain their full potential for health and well-being. This differs from health equality because it recognises the different needs of each patient and the importance of providing care according to need.

To achieve greater health equity, we should use real-world evidence to diligently characterise the barriers to accessing diagnosis or treatment that affect multiple communities within a population. It’s not just identifying these barriers; it’s understanding how they impact communities differently and, crucially, why.

We can see an example of this is in the gap in retinal health, which is also growing significantly. In 2020, 1.1 billion people were reported to be living with unaddressed vision impairment globally and this is expected to rise further to 1.7 billion by 2050, if action is not taken to improve services.

In addition, there is a marked difference in treatment and outcomes between different groups and geographical locations with 90% of people affected by this living in low-income and middle-income countries.

Women, rural populations and ethnic minority groups are most likely to have vision impairment and are less likely to be able to access care, which will have major implications on the communities they are members of, especially when it comes to the education of women and the role this plays in their communities’ prosperity.

Better research, treatment and data, as well as using real-world evidence, are key to making improvements that will alter the current trajectory from a vicious cycle of poor patient outcomes to a virtuous cycle, which works well for patients and those within the healthcare sector.

The first step to achieving health equity is to create a body of research that is representative of the whole population. This involves attracting diverse participants through offering incentives or facilitating participation outside of working hours, as well as having diversity amongst researchers to ensure culturally informed research is performed. Currently, institutions in high income countries have an unequal influence over the research carried out, which means that the cultural contexts and priorities of researchers in other countries aren’t prioritised.

Changing our approach would not only help those marginalised by the healthcare market but would help gain a better understanding of all health outcomes, because a wider and more accurate picture would be produced.

Low literacy and education levels have been recognised major factors contributing to poor eye health, so making research and information accessible to all is an important non-medical intervention in improving health outcomes. Awareness of early signs of many retinal problems may be low or ignored in favour of more pressing concerns or needs.

This is an issue because retinal disease caused by hypertension or diabetes such as diabetic retinopathy is common, just like the underlying diseases themselves. We must look to widen access to health education and empower communities with access to the right information, so they know when to seek help as necessary.

Some groups have consistently been underserved by healthcare systems or have legitimate mistrust of healthcare due to previous experiences, which has often led to them bearing the brunt of poorer health outcomes.

In the UK, people from black and minority ethnic communities are at a higher risk for some of the leading causes of sight loss, and adults with learning disabilities are ten times more likely to be blind or partially sighted. It will take time to rebuild trust between healthcare services and those let down, but it is imperative that we do so.

Wealth inequality is another major factor that affects health outcomes in the UK and, once again, eye health is no exception to this. A paper published by The Lancet in 2020 states that ‘good eye health at a community and national level has been marginalised as a luxury available to only wealthy or urban areas’.

With the definition of health equity in mind, we must recognise that it is more personally expensive for people with disabilities and additional needs to access the same treatment as others and this needs to be addressed.

A 2019 study by Deloitte found that inherited retinal diseases (IRD) incurred significant economic and well being costs for the UK population, with the individual bearing the brunt of 36% of these costs. This highlights that it’s not only prevention but treatment that could be affected by these deeply entrenched wealth disparities.

Inherited diseases come with economic consequences, which compound intergeneration deprivation and inequity. Ultimately, clinical outcomes correlate with affluence, which is a significant ethical problem that equitable local, national and international healthcare systems can address.

We have already highlighted the importance of clinical trials, real-world evidence, real-world data and the part they play in advancing our understanding of retinal diseases and new treatment pathways. We also need to look, however, at the reality and some of the barriers that are stopping people from actively prioritising their eye health.

Many individuals don’t feel they have the capacity, time, or ‘headspace’ to think about optimising their eye health, especially in the context of the rising cost of living. As we’ve already touched upon, poor healthcare outcomes are closely linked to wealth inequality and ‘multidimensional poverty’.

For example, poverty is linked to low levels of education, unsafe living conditions, disempowerment, social exclusion etc, which must be addressed if the vicious cycle is to be broken. It is only when we give people the space to focus on their basic needs that they can focus on optimising their health.

It’s also imperative that we look at the barriers clinicians face to administering the best care possible and speaking to them on a real-world level to understand why they might not be able to do so. We must ask: are the guidelines working in reality? Are we giving them the tools they need? These are just some of the questions we should be asking those tasked with keeping our communities healthy.

To conclude, we must look at the broader picture of social inequality if we are to combat health equity in retinal care. We must address the different needs of each patient individually while also looking at the real-world barriers that stop people accessing care.

Increasing the scope of current research to include those previously underserved will also be key in producing major, but necessary, changes to the healthcare landscape. We are seeing so many new advances in retina care and pathways and these steps must be taken into account as we move into a more positive cycle of outcomes for retina patients, which sees no one left behind.