Revisiting the referral letter

Specialist optometrist, Elizabeth Kime, advocates a funded referral refinement scheme for all non-urgent referrals to ophthalmology, saving NHS resources

Speaker and people

It is widely known that most ophthalmology departments are experiencing an annual increase in the number of patients needing outpatient appointments. This is not only due to an ageing population, but also because more treatments are available for eye diseases. Examples include cross-linking for keratoconus, intra-vitreal injections for medical retina and vitreo-retinal conditions.

Managing the outpatient service has been made even more challenging by the shortage of ophthalmologists, and, of course, the on-going funding issues. Long-term planning for NHS services has been placing greater emphasis on primary care, as well as on collaborative working with organisations outside of the NHS. These seem ideal conditions for optometrists to play a greater role in managing some chronic conditions. However, although there have been some excellent schemes set up in some areas, such as minor eye condition services, and ‘shared care’ schemes for glaucoma and macular degeneration, in other areas the role of optometrists has changed very little in the past 10 years. Why is this?

The profession appears to be motivated to become more involved in managing ocular diseases and patients’ problems, as can be seen by the number studying for higher qualifications. Unfortunately, the fact that the General Ophthalmic Services fee remains so low leads to commercial pressures for some optometrists, which restricts the amount of time they have available for monitoring and therapeutics. However, in my opinion, it is the reputation of optometry as a profession, and the relationship between the two professions of ophthalmology and optometry, which need to improve before the role of optometrists can change.

Optometry as a profession is not judged by the efforts of a few individuals, but by the work of all its members collectively. The main point of contact between the two professions is still the referral letter from optometrists to ophthalmology departments. Unfortunately, these vary a lot in their appropriateness and content. Naturally, ophthalmologists tend to remember the referrals that irritated them rather than the helpful ones, and rarely receive letters at all from the optometrists who have decided to monitor certain groups of patients before referring them and/or treat them in the community.

Optometry as a profession is not judged by the efforts of a few individuals, but by the work of all its members collectively


As a hospital optometrist, I am sometimes shown inappropriate referrals, for example a patient with one peripheral macular haemorrhage being referred as urgent, and a child with ADHD whose visual field test had shown a defect – not to mention the vast number of patients with physiological disc cupping and no other risk factors for glaucoma. If we want to move forward as a profession, and use NHS resources responsibly, the quality of our referrals needs to improve.

Saving NHS resources

Maybe this is unfair, but I do blame the universities to a certain extent, who do not seem to be consistently providing their graduates with the knowledge and confidence they need. However, I have also been a newly-qualified optometrist working alone on the High Street with no one to ask for advice, and am sure that I also made some inappropriate referrals in those early days. Also, where there is any doubt that a patient may have a serious condition, and then it is obviously in that patient’s best interests to refer them for further assessment. This is not the same as an optometrist referring a patient because of a lack of time to do a thorough assessment, or because of a lack of skill and/or knowledge appropriate for a qualified optometrist (such as being able to interpret a visual field test).

It is the reputation of optometry as a profession, and the relationship between the two professions of ophthalmology and optometry, which need to improve


I would like to suggest that as a profession we set up a funded referral refinement scheme for all non-urgent referrals to ophthalmology. The Local Optical Committee Support Unit could administer this. Optometrists who want to take on this role would have to meet certain requirements, such as the professional certificate in glaucoma and medical retina, and a certain amount of experience, to become ‘referral refinement optometrists.’ The patients would only need an appointment of about 15 minutes – enough time for measurement of vision, dilation and ophthalmoscopy, followed by a short discussion with the patient. The patient would then be more likely to be referred appropriately thus saving NHS resources for those who need treatment and improving the reputation of optometry.

Elizabeth Kime is a specialist optometrist, based in Newcastle.

Image credit: Getty/Skathi

Comments (2)

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  • Anonymous20 January 2020

    Northumberland Tyne and Wear LOC would like to invite Elizabeth to bring her concerns to our next committee meeting in February. We have been working hard to raise the profile of primary care optometry across the area and understand how concerns about referral quality do not help. We are running a large CET and engagement event this week with a Ophthalmologists from Sunderland Eye Infirmary, which covers ‘writing referral letters’. We would invite the team at Newcastle Eye Centre to engage similarly with the LOC. Only together can primary and secondary care support each other effectively and build relationships.
    Stephanie Cairns Chair of NTW LOC

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  • Zoe Richmond10 January 2020

    Elizabeth makes some very helpful points in her article but I wonder if primary care is more advanced in our response to the issues raised then is recognised.

    The capacity pressures impacting hospital eye services are well known and well understood within the eye health and care sector, but the benefit of a collaborative system-wide approach to service redesign, involving the whole patient pathway, is less well understood and often met with scepticism.

    A poor referral letter certainly leads to mistrust and reputational damage but as we know, many referrals are “avoidable” rather than “inappropriate” and the reputation is not always justified. If primary eye care services were more widely commissioned many of these referrals would be avoided and confidence in the system boosted.

    Primary eye care services include LOCSU’s glaucoma repeat measures and enhanced case-finding, Cataract referral filtering services and Minor Eye Conditions services (MECS) are all examples of referral refinement.

    Further referral filtering services are being developed (including pathways for refinement of referrals for wet AMD and Dry eye disease) and the LOCSU optical leads are ever ready to support LOCs and eye care systems with local service innovation.

    Where the full scope of primary eye care services are commissioned, primary care optometrists are getting involved in referral management services, supporting their peers to improve referral appropriateness and make full use of the commissioned services.

    The article is timely since the Clinical Council has just commenced a refresh of their Primary Eye Care Framework. The CCEHC recommends the commissioning of primary eye care services to support enhanced decision-making services for first contact care which support better clinical decision-making prior to any referral.

    Zoe Richmond
    LOCSU Clinical Director (interim)

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