Policy briefing: NHS’s new online hospital

What has been announced

NHS England has announced the launch of the NHS online service, a new ‘online hospital’. This will be a hospital without a physical site. NHS England describes NHS online as a “flagship reform programme at the heart of efforts to modernise the health service”, and that it will harness digital technology to fundamentally change how people access healthcare.

The service aims to allow patients to be seen more quickly by digitally connecting them to expert clinicians across England. NHS England is scheduled to see its first patients in 2027, and to deliver the equivalent of 8.5 million virtual appointments and assessments in its first three years.

NHS Online is listed to tackle nine initial conditions:

• Glaucoma
• Conditions affecting the retina at the back of the eye (including age-related macular degeneration)
• Cataract 
• Inflammatory bowel disease
• Iron deficiency anaemia
• Prostate enlargement
• Raised prostate-specific antigen (PSA) levels (not cancer diagnoses)
• Menopause
• Menstrual problems which may be a sign of endometriosis.

It is expected that other conditions will be added to the list over time.

The overarching principle is that the patient can choose the online hospital and book an appointment via the NHS app. Scans and tests are stated as being available at community diagnostic centres (CDCs), which the NHS claims will be closer to home.

What do we say

The announcement of the online hospital is a potentially innovative development that could transform how the NHS works. Ophthalmology and optometry, as data rich professions, are obvious candidates for digital innovation. Much of what both professions do centres around imaging technology, from anterior scans of the cornea to retinal imaging, and from simple photography through to optical coherence tomography (OCT) and wide field imaging technology such as Optomap.

While we can understand how access to tests and scans that are currently unavailable in primary care can add value and increase access, it is important that in an NHS where funding is stretched and resources are limited, investment is made in a considered and targeted way. As we set out in our position statement on (CDCHs), it does not make sense to duplicate the equipment that is already available in primary care. Our report Key interventions to transform eye care and eye health with PA Consulting further demonstrates how optometry offers a setting where diagnostics can take place, with fast, convenient access to specialist care for patients while also alleviating pressure on GPs and A&E.

Primary eye care has a highly trained, well-equipped workforce, who are easily accessible via 6000 optometry practices across England. The access issues seen in medicine and dentistry do not exist in eye care and it is rare that patients have an extended wait for an appointment. If data is to be gathered and reviewed asynchronously, it makes sense to gather that data in an optometry practice where the additional support and explanation can sit alongside simple data gathering, and where access and familiarity is far higher than can possibly be delivered at a CDC.

Optometry practices will work with the NHS to ensure patients are provided with the best possible care, but in many instances, we remain unconvinced that an online solution can provide a better solution. Considering each of the areas in turn:

Glaucoma

Glaucoma care can be successfully delivered in optometry. For some time, we have advocated a dual path solution: those optometrists with the appropriate qualifications to do so can work autonomously but not siloed; those who are developing their skills can work in a digitally connected environment, where oversight and collaboration delivers a safe and instantly scalable solution. There are excellent examples of successful glaucoma services around the country such as Gloucestershire.

Furthermore, our research indicates that circa 300,000 HES appointments could be released per year, with a potential annual saving of 12.92 million. With most recent research published in the BMJ indicating that glaucoma cases are projected to rise by around 60% to more than 1.6 million people by 2060, finding a practical solution for earlier detection and long-term monitoring of glaucoma, with primary and secondary care working together, will be critical.

Conditions affecting the retina

Medical retina is a wide-ranging term for varied and complex conditions, many of which can be reviewed on a routine basis within an optometry setting, utilising the expansive imaging capabilities that are already available with primary eye care. Conservative estimates suggest that over 3000 practices have optical coherence tomography (OCT) and this number is steadily increasing. Unfortunately commissioning of these services by ICBs is far from widespread limiting the ability of optometry to help the NHS tackle waiting lists.

Pre and post cataract care

In terms of assessment before cataract surgery, some may consider this an alternative mechanism to deliver patient choice conversations, but these should be delivered in an optometry setting as a continuation of the sight test. After all, the optometrist who has detected the cataract is perfectly placed to have additional conversations and explain the next steps.

Follow up care after cataract surgery, delivered face to face in an optometry setting, provides reassurance to patients and immediate solutions. The most common problem post-surgery is that patients require an updated, optimised refractive correction. This need is likely to remain, regardless of the solution delivered by the online hospital.

We will continue to engage with the online hospital service as more details emerge, advocating how optometry can be an integral part of the solution.