“A second wave, a second lockdown, a second call for re-deployment”

2020 will be remembered by generations to come as the year that an illness originating in Wuhan, China, spread around the world, killing millions of people.

As a large supra-regional specialist ophthalmology service, we believe that the Birmingham and Midland Eye Centre is a barometer of how ophthalmology services are being impacted by this pandemic.

Community optometric practices were adapting to the new normal and had resumed business, regaining patient confidence. But in the autumn, we were all plunged once again into the second wave of the pandemic. 

On 4 November, NHS England went onto the highest incident level 4. Sandwell and Birmingham saw admissions rising rapidly and infection rates reaching very high levels. The aim of the four-week national lockdown, which commenced on 5 November, is to reduce the transmission of the virus, but the current message from our Trust remains: ‘business as usual.’

Recovery phase

Over the last six months, the optometry department, orthoptic services and the visual function department have moved from a telephone-based service, to a gradual re-introduction of face-to-face consultations. The Trust’s aims were to return to 100% activity, including diagnostic and therapeutic procedures. Our teams have worked hard to support the recovery of services, while donning PPE and adhering to strict cleaning procedures between face-to-face consultations. We continue to use telephone consultations for patients who require low vision aid follow up.

NHS England and NHS Improvement have developed an Eye Care Restoration Roadmap for 2020–21, with five opportunities to transform local systems by implementing:

1. Integrated eye care pathways across primary, secondary and community care
2. Risk stratification and fail-safe processes to reduce harm
3. Remote consultations for all appointments where possible and safe
4. Virtual diagnostic clinics for all appointments where possible and safe
5. Patient-initiated follow up care.

The restoration process will mean a huge change across acute and primary eye care services and will require significant service re-design.

The restoration process will mean a huge change across acute and primary eye care services and will require significant service re-design

Sandwell & West Birmingham (SWBH) NHS Trust is currently working with neighbouring Trusts, community optometric services and private providers in the Black Country to see how services can be delivered. This is an exciting opportunity to develop an integrated eye care model for our patients.

Second wave, second lockdown, second call for re-deployment

As heads of service (HoS) in the hospital, we had been dreading the looming second wave and the catastrophic effect it would have on our recovery plans. We have previously discussed the array of responsibilities that optometrists, orthoptists, ophthalmic technicians and vision scientists have had during their re-deployment roles as the first wave of the pandemic struck, but during this second wave we had been hopeful that our services would be spared as so much progress has been made in our recovery plans.

Much to our despair, we have been informed that optometrists and orthoptists will again be re-deployed and, as HoS, we need to prepare our teams. Unlike in the past lockdown, where all the services were required to contribute towards re-deployment, trainee ophthalmologists will not be re-deployed to prevent disruption to their training.

Much to our despair, we have been informed that optometrists and orthoptists will again be re-deployed and, as HoS, we need to prepare our teams

The recovery process feels like a precarious sandcastle we have tentatively built, which may easily be swept away by the second wave.

With the second surge now in hand, there is uncertainty as to what is to come. As teams, we built resilience after the first COVID-19 surge. Although there are tools provided to help staff with mental wellness, many staff feel apprehensive about the future.

During the second wave we are not keen on re-deployment, but are well aware of the need to ‘step up’ to support the Trust in its response to COVID-19.

Education and training

Unfortunately, due to the ongoing pandemic, difficult decisions had to be made regarding training placements. This included independent prescriber trainees, approximately 20–25 graduate optometrists attending for their two-week pre-registration hospital placements, and four four-week undergraduate orthoptist clinical placements. The visual function department supports the NHS England Scientist Training Programme. This year, students have been unable to attend the department due to social distancing restrictions and small electrodiagnostic rooms.

The recovery process feels like a precarious sandcastle we have tentatively built, which may easily be swept away by the second wave

We are mindful of the significant impact the reduction in clinical placements has on the development of the ophthalmic workforce, and we need to think about how to address this going forward, with the added responsibility of caring for pre and post registration visitors in addition to our own staff.

Despite the second lockdown, patient attendance remains high. There is a need to balance capacity against social distancing in already limited clinical space. We have tried to solve this issue by asking patients to attend alone, and to arrive just prior to their appointment time. Fortunately, the weather has been good this summer as patients have been asked to queue outside the hospital until their appointment time. As winter comes, we will need to relook at how to accommodate our patient numbers within finite spaces.

As HoS, we are concerned that highly specialist services such as referrals for electrodiagnostic tests from tertiary providers have reduced this year as fewer patients visit their ophthalmologists. This could lead to an overwhelming demand for services in the future as these referrals eventually filter through.

There is no doubt that it is not just long COVID that will have a lasting impact on our patients, but delays in referral, review and treatment will result in loss of sight and in some cases loss of life

The visual function team have seen a surge in cases of malignancy. During the first lockdown, one patient missed an appointment in our medical retina service and with his optometrist. When he presented recently, he was found to have a large choroidal metastases and neurological signs suggesting cerebral involvement. He had previously had testicular cancer and was noted to have a small choroidal lesion by his optometrist late in 2019.

There is no doubt that it is not just Long COVID that will have a lasting impact on our patients, but delays in referral, review and treatment will result in loss of sight and in some cases loss of life. It is vital that we take an innovative approach to service delivery to ensure that essential ophthalmic services are retained and that we continue to deliver safe and effective patient care.

As heads of department, it is incumbent upon us to ensure that our staff feel safe and well supported through this turbulent time. They are our greatest asset in the fight against COVID-19.