“We cannot ignore the stress being felt in some High Street practices”

However, when I turned on my computer the other day I found one message that did give me pause to think. It was from an AOP member I had only met once before at an awards ceremony a couple of years ago. But if the email’s arrival surprised me, its contents gave me a shock of recognition. Mark – not his real name – was writing, he said, not because he wanted anything in particular, but just to let me know about how it felt, as the owner of a small independent practice, operating on the High Street at the moment.

In short, it ‘did not feel good’ (not the words he actually used, but you can add your own adjective). There was Mark, utterly committed to all the policies that the AOP has be campaigning for: increasing the range of clinical interventions, enhancing optometrists’ involvement in local commissioning, and prioritising environmental sustainability and ethical practice. But the sheer economic pressures of trying to operate as a small business in a deprived part of the country were, he explained, beginning to overwhelm him. Mark’s vision of optometry and the AOP’s vision were completely aligned. And while he is determined to soldier on, Mark wanted me to know that the financial realities are getting very tough.

Stories like this are not nice to hear, but are vitally important in keeping people like me and organisations like the AOP grounded in the untidy, frustrating, essential realities of life. Allowing yourself to get insulated from the sort of feedback that unexpected emails into your inbox provide makes it inevitable that you begin advocating for policy positions that are great in theory but utterly undeliverable in practice.

Let me give you a real-world example. One of the AOP’s wins in 2023 was playing our part in persuading/enticing/pressurising ministers into asking the sector to create a national pathway for extended community optometry services. That work is currently being undertaken under the aegis of the Clinical Council and co-ordinated by the Local Optical Committee Support Unit, via a series of workshops attended by clinical experts from optometry and ophthalmology alike.

Not being a clinician, I am – rightly – not directly involved in those discussions. But from the outside, if we are going to make sure that the pathway we create is one which optometrists like Mark is able to deliver, we need to ensure that voices like his are fully heard in the design process. Of course, like any pathway, the patient interest must come first: no one should ask to be paid to deliver interventions that have no patient benefit. But there is also no point in designing a pathway that is not worth any community optometrist seeking to offer it.

Key to achieving this will be deciding not merely the clinical scope of the new service, but the broader arrangements in which the work will take place. That is not just a question of the obvious such as price, but also more subtle issues like the mixture of work that the new pathway will involve. There is currently a debate about cataract surgery, with NHS ophthalmologists complaining that their colleagues working in private hospitals are picking off all the simple cases, leaving the patients who require more complex – and expensive – care to the NHS.

Making sure the new pathway includes a mixture of simple and complex cases and allows providers a reasonable financial return, while providing value to the taxpayer, is vital.

And even if the pathway is deliverable and priced properly, it will not necessarily mean that it will work for providers like Mark. If the whole contractual arrangements around it don’t work, it will never get traction. For providers, factors like contract length, demand variations and the administrative burden of reporting and compliance are critical.

Sadly, such factors are rarely prioritised in the current Integrated Care Board (ICBs) contracting culture. In addition, the departure of the Minister whose initiative this was in the recent reshuffle will not have helped; indeed, in the absence of clear ministerial pressure on ICBs to adopt the new pathway, there is a risk that it may get precious little take-up.

Whatever the result of this initiative, we cannot ignore the stress being felt in some High Street practices. Yes – there are providers who are doing well and, overall, the sector is a healthy one. But we must not be complacent: the disaster that is NHS dentistry, and the growing issues in community pharmacy – with established providers such as Lloyds exiting the market almost overnight – represent clear warnings to community optometry. It may be that my correspondent is an outlier, but I for one will be watching my email inbox closely.