19 September 2024
Organisations and charities across the eye care sector have welcomed a new report into the performance of the NHS in England and have identified ways optometry could support the future recovery of the health service.
Lord Ara Darzi, a surgeon and former health minister, was asked to perform a rapid review of the NHS.
On 12 September the Independent investigation of the National Health Service in England was published, setting out the major challenges it faces, and key themes that have emerged as avenues for repairing the system.
In a summary letter to the Secretary of State for Health & Social Care attached to the report, Darzi wrote: “The NHS is in a critical condition, but its vital signs are strong.”
The review highlighted concerns on missed waiting time targets, issues of inequality in access to care, as well as suggesting that too small a share of budget had been spent on community and preventative health services.
The report identified four factors affecting the performance of the NHS: the effect of austerity, the 2012 Health and Social Care Act and subsequent restructuring of the NHS, the pandemic, and engagement of patients and staff.
Major themes for repairing the NHS were identified, including a shift to providing care closer to home, supported by “hardwiring financial flows,” embracing multidisciplinary models of care, and investing in digital systems.
Care in the community
The Darzi review explored how and where the NHS has spent its budget, noting that the NHS has had a strategic intention to shift spending away from “reactive care in hospitals” to more “proactive care in the community setting.”
However, hospitals have attracted a greater share of NHS spending, the investigation found – quoting data that suggests since the 2006 commitment to move care towards communities: “the share of NHS spending on hospitals increased from 47% to 58% in 2021.”
The strategic concepts from the NHS include integrated care and care delivered in the community.
However, the paper noted: “The problem is that to provide high-quality, multidisciplinary care in the community requires resources that often are not there. These include the right professionals with the right skills – and the modern facilities, digital infrastructure, and diagnostics to support them.
“Over time, then, there must be a shift in the distribution of resources towards community-based primary, community, and mental health services,” the report shared.
In the future, changing the distribution of resources and delivering integrated, preventative care close to home will be strategic priorities for the NHS, Darzi identified.
Increasing demand and growing waiting times
The report identified the needs of the ageing population as a significant driver of increased healthcare needs, noting that this is associated with the development of long-term conditions.
“As the disease burden has shifted towards long-term conditions, multidisciplinary team working has become more important. Yet NHS structures have not kept pace,” the report said. “GPs are expected to manage and coordinate increasingly complex care, but do not have the resources, infrastructure, and authority that this requires.”
A key aspect of the investigation focused on waiting times across the NHS, including in accident and emergency departments and in consultant-led treatment of non-urgent conditions.
As of June 2024, the total waiting list stood at 7.6 million people, the review found, with more than 300,000 people who had waited for over a year, and 1.75 million people who had waited for between six and 12 months.
“Long waits have become normalised across the NHS and public satisfaction had declined as a result,” the report stated, adding: “Turning the situation around will take time, but it cannot come soon enough. Too many people are waiting too long for the care that they need.”
What does this mean for optometry?
To unpack the findings of the review, OT has gathered responses from across the profession, with insight from the AOP, the NHS Confederation, Hakim Group, Specsavers, the Royal National Institute of Blind People, SeeAbility, and Vision Care for Homeless People.
1 The AOP: Optometry provides a vital service
The AOP has released a policy briefing summarising the key findings of Lord Darzi’s report, as well as proposing what this means for optometry.
The report discusses underfunding, particularly in areas of health prevention and community services. Responding to this, the AOP said: “We have long argued that the below-inflation general ophthalmic services (GOS) fee increases – in the years there were increases at all – were harming the ability of the eye care sector to reach its full potential.”
Often the focus of austerity discussions is on hospitals and GPs, but the AOP highlighted the “vital” service provided in optometry, delivering a high return on investment for the patient and taxpayer, but emphasised: “The profession cannot continue to provide the service without ongoing increases in the core GOS funding.”
The AOP welcomed a recommendation included in the report for more care to be provided in community and primary care.
“Not only do our members have the skills, equipment and capacity to do more, but the NHS, at a time of significant financial pressure, can benefit from our members’ investment and can avoid the need for capital expenditure in key areas that it simply cannot afford,” the association wrote, giving the example of optical coherence tomography in diagnostic hubs.
If the Government moves funding into the community, optometrists can help to tackle the NHS backlog by taking on work that does not need to be delivered in hospital settings, the AOP noted.
The AOP also identified the need for better use of technology and connectivity, pointing out that enabling the sharing of data will provide “a better, more timely and closer to home experience for patients.”
Optometrists also play a role in supporting patients to live well for longer in their own homes, the AOP noted, reducing the need for patients to be hospitalised or moved into care homes, and so supporting social care.
The policy briefing by the AOP notes that optometrists can provide additional health checks to help the NHS shift focus towards prevention.
“By combining existing examinations, with blood pressure checks and similar, optometrists are perfectly placed to help keep the nation well and to detect cardiovascular disease earlier,” the document concludes.
We have long argued that the below-inflation general ophthalmic services (GOS) fee increases – in the years there were increases at all – were harming the ability of the eye care sector to reach its full potential
2 Specsavers: Optometry is part of the solution
In a statement responding to the report, Specsavers emphasised the role of optometry as “part of the solution” to improve access to care and ease pressures in the NHS.
Specsavers, which submitted evidence to the Darzi review, suggested that action is needed to address a postcode lottery in England.
“A consistent commissioning and funding approach will empower optometry to do even more to free up capacity in busy hospitals and look after patients in the community,” Edmonds said.
He also highlighted the potential impact an NHS-funded community minor and urgent eye care service could have, if made available across England.
“Specsavers also supports a single standardised national pathway integrating hospital eye services and High Street opticians to enable the detection, management and monitoring of stable glaucoma in the community,” Edmonds said, adding that this would make full use of the skills of optometrists and their clinical teams.
A consistent commissioning and funding approach will empower optometry to do even more to free up capacity in busy hospitals and look after patients in the community
3 RNIB: Too many people are waiting too long
Responding to the report’s “shocking picture of how waiting lists have swelled,” Vivienne Francis, chief social change officer for the Royal National Institute of Blind People (RNIB), commented: “Far too many people are waiting far too long for eye care – which in some cases could mean their sight deteriorates.”
There were 610,000 people in England waiting to start treatment in June, Francis said, pointing out around one in 13 people on an NHS waiting list are waiting for eye care.
“This is only the tip of the iceberg, as many more are waiting for follow-up appointments,” she said.
The RNIB said it welcomed the report’s focus on moving to a digital NHS and shifting care from hospitals into the community where appropriate, including giving a greater role to High Street optometry.
“Breaking the waiting list logjam will inevitably take time and RNIB wants to work with the Government, the NHS, and High Street optometrists to ensure people experiencing sight loss get seen much quicker and get the support and often critical treatment they need,” Francis commented.
“What we need now is clarity on how eye care will feature in the promised 10-year plan,” she concluded.
Far too many people are waiting far too long for eye care – which in some cases could mean their sight deteriorates
4 Hakim Group: Reform is mandatory and inevitable
Claire Slade, head of professional advancement and governance at Hakim Group, commented that the NHS review spotlights “exactly what we have known would make a big difference to the delivery of eye care services for patients across England.”
“Greater collaboration between healthcare professionals underpinned by investment in digitalisation to enable speedier communications and a shift from treatment to prevention all will contribute to making eye care services fit for the future,” she said, adding: “Wes Streeting stated that there will be no extra funding without reform which we also know can be achieved across the eye care sector.”
Slade continued: “In a growing and ageing population, where resources are already at breaking point, reform isn’t an option, it is both mandatory and inevitable if we are to suitably recalibrate to serve the UK population.”
5 NHS Confederation: Time to ‘identify the prescription’
Responding to the findings of the review, NHS Confederation chief executive, Matthew Taylor, described the report as painting “a bleak picture” of the state of the NHS.
With the review, Taylor said, “the Government has taken the first necessary step in diagnosing the problem, and the task now is to move to identifying the prescription.”
Ministers will need to work on helping the NHS to avoid a winter crisis, Taylor said, suggesting emergency funding will be required in the Autumn Budget.
In the meantime, he suggested, the Government will also need to be preparing for the future through its planned 10-year strategy.
“The fact remains that unless we restore the NHS to the long-term average funding increases it needs, accompanied with changes to the way that local services are delivered, then we will never bring down waiting lists to the levels required as well as preventing more illness from occurring in the first place,” he concluded.
The Government has taken the first necessary step in diagnosing the problem, and the task now is to move to identifying the prescription
Access to care
A significant aspect of Lord Darzi’s review explored access to care and inequalities in health, including the impact of poverty and homelessness, as well as disparities in access for minority ethnic groups and people with learning disabilities.
In a submission to the investigation, the Joseph Rowntree Foundation pointed out that people living in poverty “are getting sicker and accessing services later.”
For example, people who live in the most deprived areas of England are twice as likely to wait more than a year for non-urgent treatment.
Considering the impact of homelessness and health, the report noted that between 2010 and 2023, the number of people in temporary accommodation doubled from around 90,000 to 180,000.
“Poor health can precipitate homelessness and homelessness creates poor health,” the author of the report wrote and noted that poor access to primary and community care creates a “costly overreliance” on urgent and emergency care.
Data submitted to the investigation from the NHS Race and Health Observatory found that minority ethnic groups, particularly Asian people, experienced disproportionally longer waits for elective care after the pandemic than those from white backgrounds.
The investigation also identified “severe disparities in learning disabilities,” and referenced “multiple barriers that prevent people with learning disabilities from accessing the care that they need.”
6 Vision Care for Homeless People: Closing the gap in access
Elaine Styles, chair of Vision Care for Homeless People (VCHP), welcomed the NHS review, sharing: “The report highlights a significant gap in access to essential health services, and we believe that vision care should be at the forefront of these necessary reforms.”She told OT: “There is substantial evidence showing that people experiencing homelessness are disproportionately affected by sight problems, including refractive errors and other eye health issues. Coupled with their already poorer overall health and shorter life expectancy, the lack of access to eye care exacerbates their vulnerabilities.”
“At VCHP, we see first-hand how sight problems – often entirely preventable or easily treatable – can drastically reduce the quality of life. In many cases, providing the correct spectacles could make an immediate difference,” Styles explained.
She continued: “Unfortunately, the current NHS sight testing system often fails to serve the homeless population effectively. Even when homeless individuals access spectacles, NHS rules frequently prevent them from receiving the repairs or replacements they so often need.”
Styles expressed concerns that domiciliary eye care services in homeless hostels and day centres have “almost disappeared” due to changes in the NHS contract.
“VCHP believes that eye care should be more accessible to this vulnerable group, and reforms are urgently needed,” she said.
VCHP has proposed three changes to the general ophthalmic services (GOS) contract and regulations to ‘close the gap’ in access to vision care for individuals experiencing homelessness.
7 Specsavers: scrap unnecessary barriers to eye care
Specsavers also noted the focus on the health impacts of homelessness within the report. Over the past few years, the group has formed several partnerships and initiatives to address access to eye care services for people experiencing homelessness.This has included partnering with The Big Issue, Vision Care for Homeless People, and working with a focus group of people with lived experience of homelessness.
Edmonds shared: “We continue to call for the scrapping of unnecessary barriers to eye health services for people experiencing homelessness not in receipt of state benefit and for people who cannot leave their homes unaccompanied is another important measure.”
We continue to call for the scrapping of unnecessary barriers to eye health services for people experiencing homelessness
8 SeeAbility: This is a chance for equitable community eye care services
SeeAbility welcomed Lord Darzi’s explanation of why widening health inequalities and cuts to preventative public health services and social care explain some of the issues that the NHS finds itself in.
Lisa Donaldson, head of eye care and vision for SeeAbility, said: “In our work we know if we help children and adults with learning disabilities get the support they need, including from the health and social care system, they will thrive.”
“However, all too often people are falling between the cracks in services or reaching crisis point. Some of the data that Darzi highlights for people with learning disabilities in his report is damning, but we are pleased he has shone a light on a patient population that are often overlooked,” she added.
SeeAbility remarked on the report’s questioning of why the majority of resource has increasingly been spent in hospitals despite the knowledge that a shift to community care is required.
The charity pointed to the NHS special schools eye care service and the LOCSU Easy Eye Care pathway for people with learning disabilities as examples of solutions “to keep care out of hospitals when it can better be provided in the community.”
“Whether this report will see the sea change needed we wait and see – a litmus test will be what happens next with the NHS special schools eye care service,” Donaldson said.
Whether this report will see the sea change needed we wait and see – a litmus test will be what happens next with the NHS special schools eye care service
She added: “This produces the outcomes Darzi and the Government wishes for but needs to be commissioned as the clinically excellent model of care it currently is and funded appropriately, otherwise as the AOP has identified, it will fail at the first hurdle.”
Donaldson emphasised that sight problems are the biggest comorbidity for people with learning disabilities.
“With a new NHS ten-year plan in the offing, this is the chance to get equitable community eye care services everywhere, including the special schools and easy eye care pathway, bringing a much-needed focus on patients with learning disabilities at last,” she concluded.
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