It is currently a difficult time for ophthalmology. Demand is outstripping all supply. Ophthalmology is responsible for in the region of 7.6m outpatient appointments in 2018, making up over 10% of all hospital outpatient attendances. Ophthalmology is also responsible for approximately 6% of all surgery in the UK, performing over 500,000 surgical operations per year, with cataract being in the top four ranking of the most common NHS operations.
Perhaps most ominous of all, the UK has approximately 1.5 million people living with sight loss, which is expected to double by 2050. I’m not aware of a single hospital ophthalmology department that isn't stretched to capacity (and then some), trying to fit in the ever-increasing number of new referrals to meet referral to treatment targets, while managing a rising number of patients in the backlog.
“Investment is needed for the upskilling of the optometry workforce, electronic connections for referral through NHS net accounts, and data sharing agreements”
Everyone within the eye health field knows that this cannot continue and new ways of working are essential, utilising all medical, nursing, orthoptic and optometric staff in all areas of the community setting, as well as primary and secondary care.
Various different models of care exist, and are recommended by Getting It Right First Time and the Ophthalmic Common Clinical Competency Framework, but one of the common difficulties seems to be the sharing of information and securing the finance to commission new models.
Change is coming
One variable model across the UK is the provision of refraction services for referrals from school screening of reception age children, which, although not mandated, is recommended as an orthoptic-led and managed service by the National Screening Committee. At Bournemouth, where I am based, we provide this screening service across Dorset and are able to provide co-managed care of these paediatric patients, which means the benefit of shared learning and clinical decision making using the knowledge and skills of both professions. This also means the robust auditing of the service and its outcomes, with strong governance arrangements, and safeguarding provision. The essential requirement for this service is the provision of refraction under cycloplegia.
Other initiatives have been advocated to improve care for ophthalmology patients. This includes the creation of a standardised cataract referral form to ensure the correct information has been collected and the prospect of direct referrals from optometrists to their local NHS eye department. As always, investment is needed for the upskilling of the optometry workforce, electronic connections for referral through NHS net accounts and data sharing agreements – all of which can be barriers or obstacles to change but are not insurmountable.
“Without community optometry services, the future of hospital ophthalmology could be bleak”
In Bournemouth, we have successfully outsourced our routine post-op cataract care to local optometrists, which is working well, but seemed to take an enormous amount of effort to start.
Other optometrists are working with a commissioned service from another primary care provider. Talks continue regarding referral refinement, stable glaucoma follow-up, emergency primary care etc, while other services mandated including diabetic screening are set up and working well.
Virtual clinics are a hot topic, enabling patients to be seen closer to home, with a full range of diagnostic tests performed, seen under a protocol with consultant oversight. This results in better patient satisfaction scores, and less travelling, plus greater numbers can be reviewed. The use of High Street optometry practices for this, especially those who already have adequate equipment, would seem to be an obvious location for these services; greater collaboration is needed to see this through.
My appeal would be to get involved if you are not already. Contact your local NHS team, orthoptists, optometrists and ophthalmologists in your area. Without community optometry services, the future of hospital ophthalmology could be bleak.
Julie Dowdney is the head orthoptist and optometry service manager at Royal Bournemouth Hospital, and vice chair of the British and Irish Orthoptic Society.
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