Our response to the Government’s consultation on the 10-Year Health Plan

The future of eye care should ensure patients with an eye condition have access to an optometrist on the high street before they are driven into secondary care or GP services – other than for true emergencies. This shift will enable patients to access care closer to home, provide better use of resources by stratifying patient risk, and ensure that secondary care spends time doing the things that only they can do which in turns removes pressure on 600,000 ophthalmology patient waiting list.

Most minor and urgent eye conditions can be managed by a network of optometrists working collaboratively to avoid the need for patients to visit eye casualty or A&E². Scotland³ and Wales already have such systems, and establishing a similar approach in England would not only provide significant benefit in terms of capacity, but based upon modelling work by PA Consulting⁴, would provide a cost-effective eye healthcare solution.

The economic modelling conducted by PA Consulting shows that, at a conservative estimate, minor and urgent eye condition services, often referred to as MECS and/or CUES, have the potential to reduce hospital eye service appointments by ~200,000, A&E attendances by ~240,000 and reduce GP attendances by ~425,000. Not only could this release significant capacity, but the economic modelling also shows that if this shift was fully achieved, it could provide a net benefit to the NHS of around £30m per annum. While some of this benefit is already realised in cash terms, the additional capacity provided by this change can help to tackle the NHS backlog.

Alongside this, replicating the pockets of excellence in glaucoma monitoring and making this available to the whole country can relieve the pressure on overburdened outpatient departments. Further, by updating the medicines available to all optometrists, unnecessary, administrative referrals to GPs could be further reduced.

Modelling by PA Consulting Ltd suggests that by changing how we deliver glaucoma care and by moving routine stable patient care from secondary care to primary eye care, could release further capacity and realise further economic benefit. Conservative estimates suggest that this could release ~300,000 hospital appointments and provide a total net benefit of £13m per annum.

Eye care needs to move from the hospital setting into primary eye care. At least 50% of all current hospital outpatient activity should be delivered in a primary care optometry setting.

Currently the NHS follows a secondary care by default approach to long term conditions, but many patients could be safely seen in primary care. Take for example patients with glaucoma, independent peer reviewed analysis suggests that 70% of these patients could be seen in a primary care setting⁵. By moving low risk patients into primary eye care capacity can be released within secondary care, allowing for the increasing number of complex interventions that are emerging, as new drugs to treat previously untreatable diseases enter the market. For example, dry age-related macular degeneration, a previously untreatable disease, is predicted to become treatable in the next five years. The burden of this treatment on the NHS will be unmanageable unless the move to primary eye care is successful.

Key dependency

Data recording withing secondary care is poor. Until the data around patient complexity is more accurately recorded, identifying which patients can be discharged to primary eye care will prove difficult.

The current mechanism of contracting services that go beyond sight testing must change, if these changes are to be embedded.

The national sight testing service delivers significant benefit to the wider health system, although it has challenges; the fee level is insufficient and relies on cross subsidy by those that wear spectacles and contact lenses. Despite these challenges, what has worked well is the open-ended contracting mechanism. While there is certainly too much bureaucracy in the contract assurance process, the fact that the contract is not finite provides some reassurance.

In contrast, many locally commissioned contracts for enhanced services are short term, one-to-two-year contracts, which prohibits investment and innovation to become established. If the aim is truly transformational, contracts should be delivered to a national specification on an ongoing basis in a similar way to those in Scotland and Wales. The smallest intervention that would deliver transformation is that the minimum contract length for enhanced services must be increased. For example, in glaucoma care, if equipment must be upgraded to match the equipment that is used within secondary care (something we feel is largely unnecessary, but we are aware of strong secondary care preferences for certain suppliers) the cost of that equipment means that for primary eye care to be able to make that change, assurance over contract length is required to ensure viability.

It is also necessary that the NHS invests in primary care training. While in most cases optometrists already have the requisite skills needed to manage patients, there are some areas where additional training opportunities would widen the range of patients that can be managed. Currently additional qualifications within primary eye care, that benefit the NHS, are paid for by individual optometrists or the business they work for. While this may be similar to other professions, the training placements for qualifications such as independent prescribing and the highest glaucoma qualifications are notoriously difficult for optometrists to obtain. This could be tackled by a commitment to funding hospital training places for those that need them to further upskill the primary eye care workforce.

Key dependency

Funded hospital training places so that optometrists can, where necessary, undertake additional training.

The wider primary care voice – specifically dentistry, optometry and pharmacy – too often goes unheard, and discussions remain focussed on NHS trusts. Without this wider voice it is likely that the move from hospital to community will stall.

Currently ICBs have limited representation from primary care with a report by PA consulting highlighting that primary care representation was only present within 26% of ICBs, and when primary care was represented, it is typically a GP^6. This means that the conversations are unnecessarily focussed on what works for secondary care and how to solve challenges for GP colleagues. Equally important, ICBs must embrace their responsibility to create a more joined up local primary and community healthcare system, which requires knowledge beyond that found in the secondary care representatives who ordinarily dominate ICB decision-making.

The NHS tariff system should be looked at urgently and costs rebalanced.

Current hospital-based treatment tariffs create a bizarre incentive for secondary care to keep hold of low risk, low complexity patients. It has long been reported that the NHS tariff and pressures upon it have made it difficult for NHS trusts to manage their finances and to react to wider financial pressures⁷. The NHS tariff system should be rebalanced to enable transformation to occur.

Care that is moved to primary care must be appropriately funded.

Historically the intrinsic link between vision correction and the provision of spectacles and contact lenses has allowed the NHS to benefit from a retail cross subsidy to provide sight tests. Additional services for chronic or more acute eye problems are not amenable to this cross-subsidy model and as such must be appropriately funded, or practices will not be able to afford to participate.

• The 10-Year Health Plan should endorse four clinical interventions in eye care that demonstrate enhanced service provision. These four interventions are currently commissioned haphazardly across England; there pathways should be replicated throughout the country, without the need to constantly redesign them each time they are commissioned (Timeframe in the next year or so):
  • A national roll-out of Community Urgent Eye Services – using the skills of primary eye care practitioners to triage, manage and prioritise patients presenting with urgent and/or minor eye conditions
  • A national roll-out of the Integrated Glaucoma Pathway – including ongoing monitoring to prevent the development or exacerbation of glaucoma for patients at risk
  • A national roll-out of the Integrated Cataract Pathway – primary care optometrists confirm patient eligibility for surgery. After surgery they check for and treat post-operative complications and monitor patient outcomes
  • To transforming the potential of Optical Coherence Tomography – including in community settings and harnessing its continued technological advance.

The costs and benefits of the four system-wide changes are:

• All four interventions are considered highly feasible as they build on existing good practices and proven technologies and, importantly, also have low upfront costs to implement for the NHS and other stakeholders 
• Given the community presence and trusted customer relationships of optometrists, they also have a high propensity to reduce burdens to patients and inequalities in access to care
• These four interventions could release approximately 1.9m appointments per year across Hospital Eye Services, A&E and GPs. Of these, around 1.2m are in Hospital Eye Services, equivalent to around 9,600 appointments per year for each Acute Trust in England 
• The four interventions will also generate greater annual benefits than the costs required to deliver them, meaning an overall net gain in use of NHS resources
• Overall direct net benefits are estimated at £98m per year, assuming national roll-out of all four interventions (modelled for England, but benefits would be similar in other UK nations)
• In addition to benefits to the NHS, these changes will also bring significant (but as yet not fully qualifiable) benefits to patients, clinical staff, the wider economy and society.

• The 10-Year Health Plan must establish a new role for primary eye care. Only once primary eye care can do no more, must the patient move to secondary care. This will establish primary eye care as the true frontline of eyecare, performing a gatekeeper role, similar to that which GPs perform more widely for general medical care. (Timeframe in the next year or so).
• The 10-Year Health Plan must ensure that it is a statutory requirement that all of primary care is represented on ICBs and must rebalance the power dynamic to ensure that ICBs are not dominated by NHS provider trusts. (Timeframe in the next year or so).
• The 10-Year Health Plan must ensure that the fees paid for enhanced primary eye care services are self-sustaining and sufficiently financially attractive to providers to encourage participation in a way that does not require the service to be subsided by other activity. (Timeframe in the next year or so).
• The 10-Year Health Plan must seek to revalue hospital tariffs to ensure that complex work is funded suitably and to disincentivise hospitals from holding on to patients who could be seen within a primary care setting at less cost to the NHS, rebalancing spend in the way recommended by Lord Darzi. (Timeframe 2-5 years).
• The 10-Year Health Plan must ensure that one-to-two-year contracts are no longer the standard; contracts in the five-to-10-year range will enable true transformation that will not be at the mercy of constant NHS restructuring. To enable local commissioners to achieve this, ring-fenced, inflation-matched funding must be provided for the length of the contract. (Timeframe 2-5 years).
• The 10-Year Health Plan must ensure that optometry enhanced services move to nationally specified and priced services to remove the post code lottery. (Timeframe 2-5 years)
• The 10-Year Health Plan must ensure that at least 50% of current outpatient activity is delivered within primary eye care. (Timeframe, more than 5 years)

Pilot services show patient interactions in primary eye care enable prevention-led healthcare.

Unlike the patient interactions with GP and pharmacy colleagues, patients visiting their optometrist generally do so when they are well. While optometry detects the majority of eye disease, most of the conditions it detects are ones of which the patient was previously unaware; this invariably decreases disease severity in most instances. Additionally, optometry has a well-established, nationally commissioned home visiting service, reaching vulnerable, predominantly elderly patients in their own homes.

Since most patients who visit, or are visited by their optometrist, do so when they are in good health, this presents a unique opportunity for interventions such as cardiovascular health checks, advice around diet, weight management, alcohol intake and smoking cessation in a cohort who would not ordinarily access healthcare services. Pilots of these services are already in place and have demonstrated early success.⁸ When we recently surveyed our members, 86% were keen to offer blood pressure testing within an optometry setting. By detecting cardiovascular disease earlier, before the patient potentially has a heart attack, or stroke, further pressure can be prevented from building on social care, hospitals, respite centres and GP colleagues.

Using technology to detect eye conditions will support the drive for prevention.

Straddling this objective and the transformation from analogue to digital are the potential benefits of an emerging suite of diagnostic techniques based on examination of the retinal blood vessels termed ‘oculomics’⁹, utilising changes that may be detected within the retinal vasculature to detect disease earlier and allow interventions before ill health is manifest. In other cases, this technology can be used to predict which patients will go on to develop eye disease allowing intervention to occur before the disease is manifest10. This change could revolutionise the treatment of exudative (wet) age related macular degeneration.

Developments in artificial intelligence are likely to mean that soon, expertise that can only currently be delivered in secondary care will soon be available in a high street setting.

Good vision plays a role in preventing falls. Optometrists could provide enhanced advice on other falls related risks.

Falls cost the NHS more than £2bn¹¹ per year, with 1 in 3 of those aged over 65 falling once per year, leading to increased costs in social, community and acute settings.

Falls are known to be a leading cause of morbidity and mortality in older patients. Falls and life post fall are known to have a significant impact on the quality of life of patients¹². The home visiting sight testing service is well placed to provide opportunistic risk assessment of trip and slip hazards. These assessments, in conjunction with the maintenance of good vision, could help to reduce the falls burden.

• The 10-Year Health Plan must embed opportunistic health checks, for high blood pressure, diabetes, as well as interventions for safer alcohol consumption, weight management and smoking cessation in a fully funded manner alongside NHS sight testing services. (Timeframe 2-5 years).
• The 10-Year Health Plan should embed an older person vision strategy as a thread within the prevention agenda. (Timeframe 2-5 years).

Current health care systems are rooted in a siloed, unconnected world. Optometry and ophthalmology need to be able to share data seamlessly.

The BMA reported in 2022 that 57% of doctors working in secondary care reported delays in accessing data from primary care¹³. From the primary care perspective, at least in optometry, access to records in secondary care and other parts of primary care, is almost non-existent. This means that too often patients are moved between locations unnecessarily, test results and records are inaccessible, and professionals cannot interact or collaborate.

The digital technology that is commonly available and used in High Street optometry provides the foundation for practices to serve as diagnostic centres.

Primary eye care has undergone a significant, self-funded digital transformation, including retinal imaging and optical conference tomography scans as well as electronically shareable visual fields results and patient records. This provides significant opportunity; by utilising virtual review of images where pathology is suspected, patient travel can be reduced, saving patient and NHS time and cost, but more importantly improving productivity and clinical throughput. In addition, by integrating artificial intelligence into primary eye care, optometrists can deliver secondary care levels of expertise in a primary care setting whilst maintaining patient safety and the quality of clinical outcomes. To underpin this transformation, it is necessary to have a national system of connectivity to remove commissioning silos and interoperability dead ends.

10-Year Health Plan commitments we are calling for

• The 10-Year Health Plan must ensure that the NHS app directs patients with eye-related queries to primary eye care by default. (Timeframe in the next year or so)
• The 10-Year Health Plan must mandate a national system of digital connectivity, interoperability and communication to capitalise on the opportunities of current and next generation technology. (Timeframe 2-5 years)
• The 10-Year Health Plan must ensure access to patient health records for primary eye care. (Timeframe 2-5 years).