03 October 2025
What were once considered extended clinical roles are increasingly the norm for hospital optometry.
Across a series of Special reports into the scope of hospital optometry, OT has heard about the expanding scope of practice of the profession, the need for remuneration for advancing skills, and opportunities for progression in this career path.
In this edition, hospital optometrists reflect on the evolution of services within their departments and the factors that supported the change, ask questions of the future training of the workforce, and consider the effects of the shift towards care in the community.
Gradual development
In 2022, the Scope of practice of optometrists working in the UK hospital eye service: Second national survey, found that roles had become increasingly varied, with practitioners “often working in roles historically performed by medical practitioners.”
The researchers reported that, compared to a previous survey in 2015, glaucoma is the extended role where hospital optometrists are most likely to be involved, followed by macular assessment, while the reported level of supervision in glaucoma clinics decreased between the two surveys.
Amanda Harding, lead optometrist – glaucoma at Manchester University NHS Foundation Trust, described the involvement of hospital optometrists in the glaucoma service as a gradual development over the past two decades.
She said: “When I started, there was only me and one other person training for glaucoma. We now have 17 optometrists, either trained or in training, to deliver glaucoma services within our eye department here.”
In the beginning, hospital optometrists were seeing low-risk patients, but the introduction of the 2009 National Institute for Health and Care Excellence (NICE) guidelines on glaucoma changed how referrals came into the department, and how many, and led to the establishment of clinics for new patients.
“We weren’t just providing follow-ups, as we had been at the beginning, we started seeing all the new glaucoma patients. Over time that has evolved further,” Harding said.
Hospital optometrists in Manchester deliver nearly 50 sessions of glaucoma cover over the course of a week. With half-day sessions, this equates to 25 days of full-time clinical work, provided through a combination of virtual, face-to-face, consultant-led, laser clinics, and triage. Nearly 60% of glaucoma care within the eye hospital is delivered by optometrists.
Catherine Park, specialist optometrist in Manchester Royal Eye Hospital, shared: “We extend all the way from the first appointment – most patients will see an optometrist first when they are referred in for glaucoma from community optometrists – all the way up to performing laser and post-surgery care.”
Glaucoma care*
Multidisciplinary support
A 2024 study investigated stakeholder perspectives of optometric glaucoma care and factors influencing its success.
The paper, Providing capacity in glaucoma care using trained and accredited optometrists: a qualitative evaluation, found “broad support” for optometrists delivering glaucoma care.
Success in developing glaucoma services with optometrists is reliant on multi-stakeholder input, investment in technology and training, inter-professional respect, and appropriate time and funding to establish and deliver services, authors found.
Study authors found that all stakeholders saw potential for expanding glaucoma-related provision in primary care, “with many reporting this being key to dealing with the capacity crisis.”
Multidisciplinary working is central to the glaucoma services in the hospital eye service at Manchester, and has been from the beginning, Harding said, with the optometrist-led glaucoma services established by consultants keen to maximise the use of optometrists’ skills both in the community and in secondary care.
Funding for training has also been key to the development of the skills of optometrists, Park highlighted.
All of the optometrists within the service are funded to undertake further qualifications in glaucoma. The impact of further qualifications has also been seen in the community following NHS England funding for professional certificate places in community optometry in the Greater Manchester area.
An enhanced referral scheme is already in operation in Greater Manchester. Park suggested that this further training has had a beneficial effect on the referrals and triage of glaucoma patients entering the secondary care service.
The team is also keen to see further integration with community services. Harding shared: “At the moment, we’re limited with funding from the integrated care board for setting up a community follow-up scheme. Ideally, we would like to send some of our low-risk patients, like ocular hypertensive patients who are on drops or have had selective laser trabeculoplasty (SLT) but need yearly or two-yearly monitoring, into the community, but at the moment there isn’t the funding for them to be paid in the community here in Manchester.”
Park added: “It would mean that we can see the people who need to be seen within the hospital environment, and our colleagues have the opportunity to extend their clinical skills further.”
Waiting lists
In Gloucestershire, hospital optometrists have also been involved in glaucoma clinics for some time.
Dr Anna Warner, professional lead for optometry at Gloucestershire Hospitals NHS Foundation Trust, explained that this is provided in shared care clinics with consultants, pod clinics overseen by consultants, as well as with specialist optometrists managing patients, intraocular pressure clinics, or providing virtual clinics.
The introduction of a medical optometrist role has seen the more recent establishment of specialist clinics in which optometrists who hold the professional diploma in glaucoma can work with greater independence. Gloucestershire has three medical optometrist roles in glaucoma and medical retina.
Warner explained that the development of the roles came, in part, from having a number of highly experienced optometrists in the department with additional qualifications.
Pressures on ophthalmology waiting lists were another factor, she said: “To be able to have patients who didn’t necessarily need a consultant opinion, and have other clinics we could put them in, really helped manage that waiting list.”
Similarly, optometrist involvement in macular clinics supporting anti-VEGF treatment began in a “small way” but has grown rapidly over the past 15 years, Warner said. The large clinics now run most days, with the majority of senior optometrists working in these clinics.
Warner reflected: “It started with us reviewing these patients but discussing most with the consultants who are overseeing, but now we see the majority of patients and only speak to consultants about the more complicated ones, or where we think a treatment needs to be changed.”
The first injection clinics in 2008 began with one drug available for one condition, Warner added: “Gradually it has become more complicated, with more conditions, and more drugs.”
Building trust
Samuel Comely, advanced optometrist in the optometry department of Warrington Eye Hospital and chair of the AOP’s Hospital Optometrists Committee, reflected on how the profession has moved towards increasingly extended roles, driven by pressures on ophthalmology and the need for service provision, sharing: “Someone needed to take on that role and optometrists were the obvious people for that.”
Comely suggested that while there are “pockets of resistance here and there, overall ophthalmologists are very positive and want optometrists to progress and see more complex patients.”
Where there is resistance, and those positive relationships are not yet in place, Comely sees a positive challenge to build trust.
He explained: “It’s a good learning experience when you come across a consultant who might not be familiar with what you’re doing. They show you their way of working, you exchange ideas and end up with what is often an enhanced service due to the combined contributions of clinicians with different backgrounds and experiences.”
A 2024 position statement by The Royal College of Ophthalmologists has highlighted that “services are struggling to meet the rising tide of demand.”
With demand set to rise, pressures are expected to worsen, and, along with a need for more training places for ophthalmologists, the College shared its belief that a continued commitment to boosting efficiency by supporting primary care practitioners to be first-contact practitioners, as well as upskilling multidisciplinary teams, could support an ophthalmology workforce fit for the future.
Service redesign
Two years ago, the ophthalmology service in Inverness moved from the main hospital to the National Treatment Centre – Highland (NTC-H); a purpose-built facility funded by the Scottish Government for ophthalmology outpatients and orthopaedics.
Cora MacLeod, head of service – optometry NTC-H, and also optometric advisor for community optometry across NHS Highland, NHS Orkney, and NHS Western Isles, explained that the role for optometrists in secondary care has developed over time.
“It’s evolved over the years quite substantially, as it has in most UK hospital optometry departments. We’re constantly changing and adapting to support the needs of the service where the demands are,” she said.
The NTC-H optometry team is involved in paediatric, low vision, medical contact lenses, and diabetic eye screening, as well as medical retina, glaucoma, corneal, YAG capsulotomy, cataract assessment, and eye casualty.
Reflecting on the changes, MacLeod explained that when she joined in 2005 as project manager for a cataract and eye services redesign programme, there was no hospital optometrist input in the department.
“There were challenges, but huge opportunities to look at service redesign and utilise the skillset of optometrists,” she said.
Now seven people are part of the NTC-H optometry team, also providing services in sites across the Highlands as well as for two other health boards: NHS Orkney and NHS Western Isles.
While a small team, MacLeod said the benefit of this is that the optometrists work across a variety of clinical areas: “So it’s great for personal development and also ensures no two days are the same.”
Funding for further qualifications, and the enthusiasm of individual optometrists for personal development, have been key factors in the development of the roles of the optometrists, MacLeod suggested, while support from colleagues – such as consultants, service managers, orthoptists and nursing teams, has also been important.
An optometric pathway
The optometry team works closely with optometrists in the community, something that MacLeod feels was supported by the 2006 General Ophthalmic Services (GOS) regulation change introducing universal eye examinations, and the drive to make optometrists first port of call for eye issues in Scotland.
MacLeod told OT: “I think, certainly in Scotland, we’re really fortunate that through national policy we’re seeing a drive for ophthalmic care to be thought of as a complete pathway.”
More recently, the introduction of the GOS Specialist Supplementary service and development of a community glaucoma service, is altering where patient care is delivered. Investment in e-referral technology and IT systems is also supporting services to move to primary care.
This shift of services towards the community, and the close-working of primary and secondary care, is particularly important for service providers in the Highlands.
“The ability to have patients managed for acute eye conditions, and for community optometrists to be adequately remunerated for it, is really important – especially in remote and rural communities where travel logistics can be really challenging,” MacLeod said.
She added: “Utilising the skillsets of community optometrists to see these patients safely, but knowing they have the ophthalmology service there that can offer advice and guidance, or accept a referral if it reaches that point, is crucial for the population – particularly in the north of Scotland and the island health boards.”
Providing an example, MacLeod explained that when working in the macular service, she met a patient who lived in a remote community off the southwest coast of the Highlands where, during the winter, the ferry ran once a week. She said: “For his wet-age related macular degeneration review, he left home on a Monday and didn’t get back until the Friday for, in essence, a 15-minute appointment.”
Transferring patients who have traditionally been seen in secondary care into community optometry, allows for the redesign of services in secondary care to utilise and maximise the skillsets of the multidisciplinary team.
MacLeod believes hospital optometry will continue to evolve, sharing: “We’ve got demand going up, patient longevity increasing, rising chronic conditions – and on the flip side of that – we have developments in technology and treatments. NHS services are never static. They need to keep moving and changing, and hospital optometry is a vital part of that.”
Against a backdrop of recruitment challenges within ophthalmology, hospital optometry is well-placed with the skillset to support the future adaptations of the NHS, MacLeod proposed.
“I think we’ve already got to a point where what’s referred to as extended clinical roles within hospital optometry is almost becoming standard, and I think there will be other services that continue to develop as well,” she said.
Future workforce
Samuel Comely emphasised that a career in hospital optometry is open to anyone, whether those just starting out in the profession, or practitioners who are looking to move out of community settings.
“I think we do need to recognise that for newly-qualified optometrists, or people who haven’t worked in the hospital eye service before, it could be potentially overwhelming. It does concern me that the increasing complexity might be putting people off from applying, and it needn’t,” he said.
Emphasising that training and progression pathways are always provided, he highlighted that newcomers into hospital optometry “don’t have to do everything at once,” and added: “They should feel they can approach their local hospital or the AOP to find out more about the hospital eye service.”
A benefit of the unique setting of hospital optometry is the multidisciplinary way of working. Comely said: “You’re never really on your own in the hospital eye service, there is always some support.”
Change is afoot for hospital eye services, and optometry in particular, which creates questions for the future of the profession.
Comely explained: “There are a lot of changes: the new training schemes, increasing complexity of clinics, and more work being taken on by private hospitals, and community optometry clinics.”
A key question for the profession currently is: where are the next generations of hospital optometrists going to come from and how are they going to be trained?
One answer will be to encourage applications from optometrists who may not have prior experience in an NHS Hospital and supporting them with in-house training and higher qualifications – something that the hospital eye service has achieved “very successfully” in the past, Comely said.
The changes to how optometrists are educated and qualify, with the introduction of new Master’s programmes and upcoming retirement of the pre-registration model, has posed questions of how hospital eye services can accommodate students for placement periods.
This is something that the profession is discussing, Comely shared, emphasising that the traditional hospital pre-registration scheme has been highly valued by the hospital eye service. He added that the profession is eager to find a new model that will continue to encourage optometrists into hospital optometry as early in their career as possible.
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