“If we want to change eye care, what we really need is data to be collected as business as usual”
Why optometry and ophthalmology have to work together, and be prepared to learn and feed back, Melanie Hingorani tells OT
29 June 2021
We urgently need to address the many barriers that are causing delays for patients with eye conditions. Even before COVID-19, in the world of optometry and ophthalmology we knew there was a big problem brewing. We had escalating demand from older and more diabetic patients, and we had big delays despite having far more treatments to offer patients. We just weren’t coping and patients were being harmed.
And then COVID-19 came along – and it either shut down services or dramatically slowed them. We now have a huge backlog of patients – how many, we simply don’t know. People with glaucoma and retinal problems need to be seen on time and the truth is they have not been.
The extent of the problem is greater than we can imagine too. We are talking hundreds of thousands of patients who are being affected. We know how many new patients are waiting, but we lack good data on who these patients are, and also how many follow-ups there are nationally – and that is where the risk is. It is quite frightening.
The assumption that we can’t see patients virtually because they won’t like it, or they will be inept digitally, has been proved wrong
However, COVID-19 has opened peoples’ minds to what is possible – and created opportunities for us to do things differently and get things done more rapidly than NHS bureaucracy would have allowed before.
A new process has emerged where the patient only needs to come into hospital for the diagnostics; at a separate point the clinician then reviews the test results, and if the patient is fine, they are sent a letter, and if they are not, they have a video consult follow-up.
The assumption that we can’t see patients virtually because they won’t like it, or they will be inept digitally, has been proved wrong. Actually, patients find they like the luxury of sitting in their own home for their consultation.
There is much evidence to support the role of optometry to tackle the backlog. But I am aware of a disconnect in ophthalmology between what we think patients’ perception of optometry is, and what patients actually think. For example, I have been to meetings where reps from advocacy groups argue that patients are worried that they’ll go for a glaucoma check and ‘get flogged a pair of glasses that they don’t really need,’ and this hard sell will put off people from economically deprived backgrounds from accessing eye care.
My experience through the shared care work I have done does not bear this out. Patients were really happy to see their optometrist; they already knew them, and it was so much more convenient to arrange a visit locally.
When shared care pathways work less well, the reason is a lack of an effective partnership between ophthalmology and optometry. We have to work together; both sides have to be prepared to learn and feed back on what’s gone well and what’s gone badly. If we put that effort in from the beginning, it can work brilliantly. Issues occur when commissioners do not talk to the hospital and decide to run a repeat measures scheme in optometry that is completely divorced from everything else.
“The digital revolution is exciting and coming to eye care”
1. Digital hubs
“In effect these are giant reading centres that receive in a source-agnostic way diagnostic tests and images data from everywhere in that geography. It could come from optometry, community diagnostic hub, or a hospital. A bank of multidisciplinary decision makers including optometrists access the data and can make decisions, produce reports, and so on. By pulling all the data into one source, it gives us the opportunity to develop artificial intelligence, as we are seeing at Moorfields at its department of digital medicine.”
2. Home vision monitoring
“This approach means that patients are in their own diagnostic hub while in the comfort of their armchair. This can include video consultations, access to records and advice, information support, and patient-initiated follow-ups. The ability of patients to measure their own vision and even take pictures of the back of the eye is becoming an increasing possibility.
We are let down by a lack of routine national data collection at any level of detail. In hospitals, we don’t diagnostically code: our backlog of ophthalmology cases can only be divided into ‘new,’ ‘follow-up,’ ‘child,’ and ‘adult.’ This means we do not know who has got what disease; we don’t capture how many people are seen via optometry referral nor where the variation in referrals is coming from. With optometrists performing enhanced roles, how many patients are going through this route, and at what scale was hospital visits avoided?
If we recognise that we want to change eye care, what we really need is data to be collected as business as usual – certainly regionally and ideally nationally – to not only see what we are doing now but plan for the future. This is crucial in order to put together the busines case for the better pathways that we all want.
The question of renumeration is sensitive, but we need to be grown up and achieve a consistency of payments. Some clinical commissioning groups are paying one thing, some are paying another; where is the evidence to support that is the right approach, underpinned by logic and evidence related to the risk and complexity of the work? There is a huge difference in terms of the time and knowledge you need to manage simple post-cataract eye surgery, versus a glaucoma assessment where the patient could go blind if you get it wrong.
Nobody wants a system like GOS, where optical practices in the community feel they are using their business to prop up the NHS. But asking the NHS to pay optometrists the same fee that it would for a patient going into the hospital is not going to fly. It has to be more affordable.
While we can talk about adopting a GOS+ approach in England that replicates the model in Scotland and Wales, the direction of travel from NHS England is to decentralise commissioning.
The first thing I would do is collect data on what’s being paid for schemes nationally. We need to see the variation and understand what is reasonable using health economics modelling. In hospitals, our tariffs and pricing have a methodology behind it that takes into account the overheads and what we did for the patient, divided by how many patients we see. Without the same overheads in High Street practice, let’s explore what the economics are that justify the difference in what a hospital is paid versus community optometry.
About the author
Melanie Hingorani is clinical lead for the National Eye Care Recovery and Transformation (NECT) programnme. She is also a consultant ophthalmologist at Moorfields Eye Hospital, chair of UK Ophthalmology Alliance, and chair of professional standards at the Royal College of Ophthalmologists.
- As told to John White.