Optometry in hospital eye services: a changing picture

With this article, OT launches a new series of Special Reports exploring changes in hospital optometry.

Scope of practice

The changing services delivered by hospital optometrists was the subject of research by Harper et al in: Scope of practice of optometrists working in the UK Hospital Eye Service: Second national survey in 2020.

The research built upon a previous survey, completed in 2015, and heard from 90 hospital eye service leads in England, Scotland, and Northern Ireland. No responses were received from Wales.

Between the two surveys, the authors reported a continued evolution of the scope of practice of optometrists in hospital eye services in the UK.

Paddy Gunn, consultant optometrist and head of optometry at Manchester Royal Eye Hospital, and a co-author of the report, explained that comparing results from the two surveys showed that areas such as glaucoma, age-related macular degeneration, cataract, and corneal services, are embedded in the role of hospital optometrists.

“I think that optometrists within hospitals are very familiar faces within those services and that’s not changed. But it is exciting to see new extended roles are becoming more common,” he said, pointing out that in the 2015 survey there were no optometrists working in uveitis clinics, while there were 20 in 2020.

The report suggested the scope of practice of optometrists in UK hospital eye services has embraced a “growing range of service contributions well beyond the traditional areas.”

Rosalind Creer, lead optometrist at Manchester Royal Eye Hospital and report co-author, said: “I think we would both agree that the role, or the scope, of the hospital optometrist, is much broader now and is probably still evolving.”

Gunn agreed that the perspective of what a hospital optometrist is has changed. He shared: “Within our own organisation, the hospital considers an optometrist to perform quite comprehensive roles across most of our services.”

“I think if you went back 20 or 30 years, optometrists were a really important part of the hospital, performing quite specific roles within what would be considered a smaller scope of practice,” he said, continuing: “I think the perspective of what an optometrist can contribute to ophthalmology services has changed quite dramatically.”

I think the perspective of what an optometrist can contribute to ophthalmology services has changed quite dramatically

 

New clinics

Vijay Anand, head of optometry at Moorfields Eye Hospital NHS Foundation Trust and chair of the AOP’s Hospital Optometrists Committee, suggested: “When you look at the data, probably the majority of individuals that work in hospital optometry are now doing these extended role clinics, so they’re not really ‘extended,’ they are part of our role now.”

Diplomas and professional and higher certifications have enabled optometrists to take on “the next level” of work, he suggested.

Using the example of the introduction of intravitreal injections, he noted that a workforce was required to assess patients for the treatment, which needed to be provided on a regular basis, and optometrists were well placed to take on the role.

The hospital has four optometrists on-site in intravitreal injection clinics assessing 70-80% of patients, he said.

Anand reflected that the scope of practice for optometrists has grown “exponentially,” sharing that when he began working at Moorfields two decades ago, the team was made up of approximately 25 full-time equivalent optometrists. Now, the department is up to 90.

“It’s a huge expansion and that growth hasn’t been in those core services, it’s been in the subspeciality of medical services,” he said, adding: “It’s become the mainstay of our work.”

Chris Steele, consultant optometrist and head of optometry service at the Sunderland Eye Infirmary (SEI), shared that the hospital optometry department was an early adopter of extended clinical roles in the 1990s, initially in cataract pre- and post-operative care.

“The scope of practice has expanded into many services once considered the sole domain of the medical profession. We now have highly trained, experienced optometrists working in cataract, medical retina, and glaucoma clinics, as well as the emergency department,” he said.

A wide scope of clinical practice at SEI has enabled many optometrists, most holding postgraduate higher qualifications, to work “at the forefront of modern clinical practice,” he added.

Steele suggested the needs of an ageing population have bolstered the shift in roles, sharing: “An ageing population has significantly increased demands on ophthalmology in recent years, especially with the ever-growing number of new treatments available that often require frequent follow up of patients in outpatient clinics. The pressure on outpatient services to see more patients has therefore increased enormously.”

Supporting the need

The Royal College of Ophthalmologists workforce census in 2022 indicated that 76% of NHS ophthalmology units did not have enough consultants to meet patient demand. Hospital optometrists speaking to OT highlighted this capacity pressure as a key factor in the expansion of roles. 

Discussing shortages in ophthalmology, Steele noted a “pressing need to re-evaluate the current scope of practice of hospital optometrists working within multidisciplinary teams in secondary care in the UK.”

“Hospital optometrists are well placed to further expand their roles along with other multidisciplinary healthcare professionals,” he added.

Dr Waheeda Illahi, consultant optometrist and head of optometry services at Birmingham and Midland Eye Centre, explained that with a growing backlog coinciding with an “acute” shortage of ophthalmologists in the UK: “NHS policy developed to reflect the changes in demand and national guidance specified the need to utilise the skills of the non-medical ophthalmic workforce has had a major impact on developing the role of ‘extended’ and ‘advanced’ clinical practitioners.”

As a lead in an optometry service in a tertiary referral centre where optometry and orthoptic services had more traditional roles, Illahi described the “joint determination” of herself and Rosie Auld CBE, then-head orthoptist, to illustrate that “optometrists and orthoptists had the potential to enhance their existing knowledge and skills in order to take on extended practice roles.”

“In our experience, the main shift comes from a supportive consultant ophthalmologist or a clinical director who is willing to embrace change,” she said.

There is an incredible variation in the scope of practice of hospital optometrists across the country

 

Firm foundations

The development of optometrists’ knowledge and skills, including the adoption of independent prescribing, has increased autonomy within hospital clinics.

The Harper et al 2020 survey of eye hospital leads, respondents indicated an increase in the use of independent prescribing in clinics from 18% in 2015 to 67% in 2020.

Creer pointed out that the numbers of optometrists gaining additional qualifications, alongside published literature, have provided backing to support the expanding role of optometrists in the HES.

Thomas Hamper, specialist optometrist at Manchester University NHS Foundation Trust and a member of the AOP’s Hospital Optometrists Committee, agreed that the drive for changes in the roles of hospital optometrists could be drawn from a desire to undertake further education.

“I think it is quite a happy combination of optometrists being lifelong learners, keen to innovate and expand their roles, meeting a hugely increasing demand, and the need for an increase in resources in ophthalmology,” he said.

“I think it’s the right time for those two areas to coalesce,” he added.

With changing roles and demands on hospital optometry, Anand noted: “I think the biggest challenge is where do we continue to get our workforce from? How do we keep up with the demand with the workforce we have?"

This question is particularly prevalent in the minds of leaders in optometry departments as universities roll out Master’s courses redesigned to meet the General Optical Council’s new education and training requirements – a topic OT intends to return to in a future report.

A key dynamic to shaping the workforce is ensuring optometrists moving from community High Street settings receive the right training to work alongside colleagues in the hospital environment.

This has required good systems of governance, along with training, auditing, reporting and comparing results, Anand said.

“It’s not just that we’ve said we can do this – we’ve proven it as well,” he added.

One concern with shifting responsibilities is that optometrists might find themselves in roles where they do not feel adequately trained or supported, Illahi recognised.

“It’s important that the optometrists are aware of their limitations and work within those,” she said.

The upskilling requirement can create some cost pressures for departments that need to be weighed up in order to release the member of staff to complete the training.

“While pressure to achieve the required level of clinical competency should be controlled, reduced workloads during training will have an impact on cost efficiency,” Illahi explained. “The important issue is the ultimate capability of the extended and advanced practitioners to ensure a safe, efficient, and effective service is delivered.”

It’s not just that we’ve said we can do this – we’ve proven it as well

Appropriate recognition

Optometrists working in hospitals fall under the NHS Agenda for Change pay scale, which ranges from Band 1 through to Band 9. OT’s interviews for this feature indicated that many hospital optometrists fall into Band 6 or 7.

The NHS Careers website indicates that Agenda for Change pay rates, dated from April 2024, can range from £37,339 to £44,963 for Band 6 and £46,148 to £52,809 for Band 7 depending on experience. A high cost area supplement is also in effect. 

With the expanding scope of practice of optometrists in hospital eye services, a question remains around remuneration, and whether the bands reflect the experience and skill of the workforce.

Considering this question, Steele shared his perspective with OT: “In certain regions of the country, such as the North East, community optometrists, on average, earn at least 20% more than what is offered to hospital optometrists on the Agenda for Change NHS pay scales.”

This could then, therefore, create challenges in recruiting for these specialist roles, particularly in light of the cost-of-living crisis, Steele said.

“The current level of pay for optometrists working in these cutting-edge specialist roles, with often very challenging caseloads, does not truly reflect the high levels of responsibility and accountability that are required,” he shared. Steele emphasised that this is his view of the situation, and not an official position of the Trust.

In order to address this issue and recognise clinical responsibility and accountability, he suggested that more hospital optometrist posts involving advanced clinical roles should be funded at Band 8a or above (between £53,755 and £60,504 according to 2024 figures).

“This would almost certainly improve recruitment into hospital optometry in the short term and encourage retention of existing, very experienced staff in the longer term, who may otherwise be lured into far more lucrative ways of practising their hard-earned optometry specialist skills.”

Optometrists primarily engaged in traditional optometry roles within hospital settings are often remunerated as Band 6 or 7, making it difficult to recruit full time members of staff, meaning many optometrists divide their week between hospital and community optometry to make up for the financial shortfall, Steele said.

Optometrists are working autonomously, developing in skills and understanding, and often adopting roles in management, training or research, and developing services, Gunn noted.

He shared: “I think there is definitely more that could be done to make sure that appropriately-banded opportunities are there for those working in these developing roles. It’s just about making sure that everything optometrists have done is reflected fairly in terms of their career opportunities,” he said.

It’s so important not to lose sight of being good at those optometry-specific skills, because even if it feels basic to us in our day-to-day, they are not basic to the person benefitting from them

 

Unique speciality

Optometrists working in hospital eye services are “unique” in the functions delivered, Hamper suggested.

Comparing the role with that of optometry in the community, he noted: “The skill mix in terms of expectation management and patient counselling is often similar. By the time someone has reached us in those clinics, there can be nothing else on the cards at that time. Sometimes it’s about balancing expectations and reality, but often the upside is that we can then do something to improve a person’s current situation.”

Hamper emphasised the importance of the roles considered ‘traditional’ or ‘core’ within optometry in hospital settings, warning that these should not be undervalued.

“It’s so important not to lose sight of being good at those optometry-specific skills, because even if it feels basic to us in our day-to-day, they are not basic to the person benefitting from them,” he said.

With the pressures on ophthalmology services, he added: “We don’t want to be used as backfill for the shortfall in ophthalmologist numbers. I think a lot of colleagues share the opinion that it’s good for optometrists to have extended roles, but not at the expense of optometry-specific specialties.”

Creer also highlighted how vital core optometry skills are, sharing that in the hospital setting: “These are really complex patients and it takes a lot of skill to do these roles. That is never going to change – there will still be a need for that role.”

“It’s really important that we don’t forget about that and make sure our optometrists are skilled in those areas because that is going to be key for provision of service,” she added.

Gunn agreed, sharing: “I think ophthalmologists and other health professionals within the hospitals do rely on the very specific knowledge that we have as optometrists and that we are trained in. That knowledge, skill, understanding – the uniqueness of an optometrist – is important.”

Big picture

Considering the effect of the expanding role of optometrists within the multidisciplinary hospital teams, Illahi shared: “Optometrists, orthoptists, and ophthalmic nurses undertaking extended and advanced practice roles have a significant positive effect on waiting times resulting in a safer, effective, and efficient service.”

Workforce planning at a national and local level needs to reflect changes in service delivery to ensure personnel and funding for the expanding optometric services, she added, balanced against providing medical staff with opportunities for training.

Anand reflected: “I think we’re a very strong workforce that has shown we can deliver high quality clinical work underpinned by good governance.” He added: “We have shown we can expand those skills, not just in a clinical setting, but into the four pillars of advanced practice.”

This provides a solid grounding from which to take hospital optometry forward, Anand suggested, and create more opportunities for career progression.

“It’s a very exciting time to see what the scope is for where we can help and make changes for the benefit of the patients, because ultimately that’s what we’re here to do,” he said. “Anything we can do to make the journey and lives of patients better is what we should be looking to do.”

 

OT will continue to explore the hospital optometry workforce in future Special Report features, including career progression, and the private sector. To share your views on the topic, get in touch: newsdesk@optometry.co.uk

OT would like to thank everyone who contributed to this article for their time in sharing insight, views, and commentary.