The Postcode Lottery of Cane Training

Chris Owen is a regular contributor to Fight for Sight. You can find his previous blogs here.

Last year, £125 million was spent on vision and hearing sensory services across England. This sounds a lot but when you break it down for each of the approximately 1 million people it is designed to support, it is less than £120 each. This is a drop in the ocean compared to the £131 million spent on the expenses for 650 MPs.

To be clear, just because people are entitled to these services, doesn’t mean we use them each year. It’s a little bit like going to the doctor’s – we are all entitled to visit our GP, but we only need to go when we’re ill. In reality, the evidence shows that only between 15% and 20% of visually impaired or hard of hearing people use these services each year. Even so, £125 million split between 211,000 people is still less than £600 per referral. Considering the vast majority of this spend goes on people costs, there is not much left for a vibrating alarm clock or, in my case, a long white cane.

But what do these services provide and why are they so important?

There are over 2 million people in the UK with some form of sight loss. Of these, around 350,000 are registered sight impaired or severely sight impaired but only about 10% of these have zero vision. I am one of the people classed as severely sight impaired, I have most of my peripheral vision but my visual acuity is measured in the number of fingers I can see. My local council’s sensory needs team has worked with me to adapt my home with useful accessories such as lamps, talking alarm clocks, tactile dots for appliances and using a long white cane. All this support means that I am less reliant on others and my self-confidence remains high whilst I come to terms with having a degenerative disease.

When I first started considering using the cane, I was surprised to learn that, before being let loose on the streets of Reading alone, I had to go through a training programme that could take up to 8 weeks to teach me how to hold it, how wide to sweep it and how to cross the road, climb stairs and use an escalator safely. Only once I had proven I could do this, was I allowed out unsupervised.

The other thing that surprised me was how few visually impaired people use a white cane. Numbers are shaky but, according to The Braille Foundation, only between 2% and 8% use one. It’s not as though most of us have guide dogs either, there are only 4,800 working guide dogs. In reality, most prefer to use either a sighted guide or nothing at all.

I began my white cane journey in September last year and, in January this year, I embarked on the next leg by applying for a guide dog. It was during this process that I found out that not all applicants have the same level of competence in using a long white cane. This intrigued me and I wanted to explore further so decided to reach out to other cane users.

I spoke with six other people from across the UK. All of whom are registered as blind but with varying levels of vision. Of everyone I spoke to, all bar two used their canes just about every time they leave the house. One of these has a guide dog and the other has additional conditions making it difficult to navigate independently over long distances.

Both Neil and Lea from Cheshire and Leeds respectively, received training from their local authorities around 10 years ago. For Neil the quality of the training was, in his own words, “amazing” with his support worker, Lyn teaching him how to use his cane in all environments and situations.

Whilst Lea’s training was also quite thorough one key situation was missed – how to safely get on and off an escalator. This caused significant angst when, on a trip to London, they had to work out how to safely get down to the underground platforms at a busy Euston Station.

Lucille from Kent who has Retinitis Pigmentosa (RP) started using her cane over 10 years ago and, before getting her guide dog, Mabel, would use it daily. Training was provided by the Kent Association for the Blind (KAB) on behalf of Kent County Council. She had three very comprehensive sessions learning to navigate around the house and into the local town centre. As Lucille’s vision has degraded she has had further training from both KAB and Guide Dogs to help rebuild her confidence and be safe when out at night.

Conversely for Lynne and Zoe from Hertfordshire and Oxfordshire, their training experiences missed a number of key skills, causing them both to revert to online tutorial videos to learn how to navigate public spaces, climb and descend stairs and get on and off escalators correctly. It took almost 5 months for Lynne’s training to start – significantly longer than the Royal National Institute of Blind People’s (RNIB) guideline of 28 days.

For Zoe, by the time she had a follow-up session in 2018 (8 years after she first began to use her cane) she was already deemed to be a proficient user and no further training was required.

Sadly their experiences were not uncommon, another person I spoke to from South London who was left totally blind after an accident had some traumatic experiences when learning to use their cane. Their mobility needs were restricted to visiting the local shop and a nearby bench to sit in the sun. They had three or four bouts of training, some of which lasted several months.

One of the early bouts was so bad, with the client being accused of not prioritising their mobility enough that it drove them to tears. Thankfully this was only one experience and other trainers were much more understanding of their priorities.

As you can see, not one of us has had the same training experience and, although in most cases this is by design, there is a very broad gap in the skills we are taught.

In order to be a registered Orientation and Mobility (O&M) specialist, you must undergo extensive training first as a Vision Rehabilitation Worker. There are currently two training providers in the UK, according to the Rehabilitation Workers Professional Network (RWPN). RWPN is the professional body for Vision Rehabilitation Workers and Habitation Specialists and its main objectives are to “set and maintain professional standards, promote the values of vision rehabilitation and support the workforce in the day-to-day execution of their role”.

Simon Labbett, the chair of RWPN, explained that vision rehabilitation workers (also known as ROVIs or O&M specialists) take 2 years to train. This training covers a broad set of environments including safely using public transport.

When starting to train someone, the ROVI will take time to understand the client’s objectives and abilities and will then adapt the training to suit.

I contacted a number of local authorities to understand their approach to vision mobility training and just three, including my local council of West Berkshire responded.

Helen Hickey, the West Berkshire Sensory Needs Team Leader told me about how the team is set up and how they approach mobility training. West Berkshire has three part-time ROVIs. Helen explained “the aim of our unit is to enable clients to manage their sensory loss in all aspects of their daily lives, and so achieve the greatest amount of independence as possible.” As no two peoples’ sight loss and mobility needs are the same, a plan will be developed between the instructor and the client. West Berkshire have also developed a detailed Mobility, Orientation and Long Cane training guide which contains all the standard information to support the training.

John Ferne-Webster, Oxfordshire County Council’s sensory needs team manager told me that they employ four full-time fully-qualified

ROVIs for the county. The individual training programmes are developed based on client’s “needs, abilities and wants”, thereby providing a broad overview of mobility, independent living and support with specialist communications.

Speaking to Isabelle, the sole O&M Specialist at Reading Borough Council, she explained that there are many challenges being the only rehabilitation officer for such a large metropolitan area but she always strives to ensure the service offered is of the highest standard and is in accordance with RWPN guidelines. Being an in-house provision helps to ensure a consistent and holistic approach.

Isabelle works closely with other service providers such as the local bus company to create a safe space at the depot for public transport training before further lessons on an active service. She also takes advantage of other partnerships (for example with the Reading Association for the Blind) to provide group cane training in the town centre.

Each of the four nations of the UK has different guidelines for the number of rehabilitation workers at each local authority. In Wales, the Senedd advises there should be one ROVI for every 70,000 people. Westminster does not have any national guidelines for England, but the RWPN advises its members there should be one rehabilitation worker for every 117,000 people.

When questioned, Edward Argar MP, Minister of State for Health responded that the Department has no estimates for the number of sight loss rehabilitation officers in the UK and there are “no specific workforce plans in place” for this area. Thankfully, the RWPN has a clearer picture from their membership records, showing there are somewhere in the region of 300 in England, 40% fewer than the guideline of 484.

The rest of the UK fares significantly better with a deficit of 6%, 36% and 10% for Wales, Scotland and Northern Ireland respectively. Once

again showing how much England is lagging behind the rest of the country in its social care approach.

With an estimated 59,000 sight loss referrals per year, each ROVI should be responsible for approximately 120 cases giving each client approximately 13.5 hours of support. With the current workforce, this time is more like 6.5 hours, not very long for home assessments, 8 weeks of cane training, vulnerable person support and so forth. Is it any wonder the training provided is so mixed?

To support local authorities in developing the best possible service for its visually impaired clients, the RNIB calls on those developing the provision to follow its 10 principles of good practice in vision rehabilitation. Phil Ambler, RNIB’s Country Director (England) outlined that these principles state that clients should be contacted by phone within 2 working days of a referral and there should be a face-to-face visit from a specialist within 28 days. Based on the feedback from everyone I spoke to, it is unfortunate that many local authorities are unable to achieve these targets, leaving us struggling at one of the most critical times in our vision impairment journey. Hardly surprising considering how stretched the teams are.

Whilst the primary focus for these services must always be the clients, there is also a very strong financial argument for improvement. A study in 2017 commissioned jointly for the RNIB and Sight for Surrey (the third-party charity providing rehabilitation services for Surrey County Council) found that by providing a suitably funded and resourced service resulted in a massive cost avoidance in other provisions. In the year 2015/16, Sight for Surrey spent around £920,000 for 702 referrals, a cost of approximately £1,300 per referral. This resulted in an estimated cost avoidance of almost £3.5 million from improved functional independence, personal safety, emotional wellbeing and social participation. This is an avoided cost of almost £4,900 per person. To expand this nationwide, this means by increasing sight-loss rehabilitation spending from a mere £35 million to just £76 million is likely to result in avoiding costs of almost £300 million per year, a massive saving for public services struggling to cope with demand.

At a time when so many essential services are being squeezed, there is a very real risk that the sensory needs provision will also be in the firing line and, based on feedback it seems some already are. This is a massive worry as it is likely to make an already vulnerable and isolated community even more so, thereby increasing the burden on other areas of the social care system that are already at breaking point.

So, what’s the answer? Vicki Foxcroft MP, Shadow Minister for Disabilities explained that the first step must be to listen to those of us for whom these services are essential and understand how they can be shaped to better support within a properly costed and resourced framework.

This is an excellent start and to combine this approach with the current system of allowing Helen, Isabelle, John and all the other Sensory Team leads to operate autonomously would mean the sight of a visually impaired person walking along the streets, long cane confidently in hand will become common-place in our villages, towns and cities.