Why are refractive corrections excluded from the public benefit packages in the UK and in Sweden?

Abstract

To the Editor, I read with great interest the guest editorial by Ramke and Logan on visual impairments caused by refractive errors and the challenges of providing accessible and affordable refractive care to all individuals with refractive errors. I share many of the authors' views and would like to add some further reflections focusing a question that is seldom asked: why are refractive corrections excluded from public benefit packages? What are the reasons for this exclusion in countries like the United Kingdom and Sweden? Health care needs related to refractive errors are diverse and range from the rather modest needs of individuals with presbyopia or mild myopia to the highly significant needs of individuals with prominent refractive errors resulting in low uncorrected visual acuity. Refractive errors belong to the field of medical science, and they are provided with diagnostic codes in the ICDsystem. Interventions to correct refractive errors are performed by medical means and require the skills of registered health care professionals. However, in the United Kingdom and Sweden health care needs associated with refractive errors are not covered or assessed in the public health benefit packages on the same terms as other medical conditions affecting the visual system. This exclusion has received surprisingly little attention in these two countries, which are otherwise known for high shares of publicly funded health care and ambitious commitments of allocating health care resources based on health care needs. In the UK, individuals who belong to certain eligible groups are entitled to free eye tests and optical vouchers provided by the National Health Service (NHS). However, people with refractive errors who do not fit into any of these groups must finance refractive corrections themselves. In Sweden, conditions are even more stringent: only individuals under the age of 19 years are eligible for grants for glasses. All other individuals with refractive errors must finance corrections themselves, regardless of the degree of the refractive error and its impact on the individual's visual acuity. In ethical theory, needs depict states of dependency. Health care needs relate to some sort and degree of disability. Individuals with refractive errors need refractive corrections, and individuals with high degrees of refractive errors need corrections to manage most things in their lives: to perform certain jobs, to carry out everyday tasks and to accomplish various life goals. The health care interventions needed to correct refractive errors, such as spectacles, contact lenses or refractive surgical procedures, are very efficient and have a potential to move individuals from a state of severe visual impairment to a state of perfect visual acuity. When assessing needs and health care resources in prioritisation and allocation processes, it is important to regard the noninterventional state relative to the postinterventional state. The noninterventional state when it comes to refractive errors would be most accurately represented by the state prior to correction, i.e., the uncorrected visual acuity. Defining visual impairments in terms of bestcorrected visual acuity (BCVA) in epidemiological research comparing different health states and their impact on quality of life does not give a proper basis for assessments when decisions are to be made in these matters by politicians and government policy analysts. Today, the exclusion of refractive corrections from the basket of goods receiving public coverage in the United Kingdom and Sweden is an apparent inconsistency and the policy must be revised. Publicly funded health care agencies in both countries must start assessing the needs of individuals with refractive errors and prioritise health care interventions associated with them – as would be the case for individuals with other health care needs. By taking their fair financial responsibility for refractive corrections, these countries would also be sending a clear signal to the international eye health community and strengthen the efforts pointed out by Ramke and Logan.