Giving optometry a voice within healthcare reform
With the Health and Care Bill up for discussion in the House of Lords, and delays in the proposed transition to Integrated Care Systems, OT considered what the changes could mean for the profession
20 January 2022
Introduced to Parliament last year, the Health and Care Bill moved into the committee stage in the House of Lords this month, during which time, potential amendments and changes can be made to the Bill.
As part of the reform plans, Integrated Care Systems (ICSs) are set to replace Clinical Commissioning Groups (CCGs). Should the Bill pass, it will give ICSs a statutory footing, establishing them legally and creating the new Integrated Care Boards (ICBs) as NHS bodies.
This was initially set to take place in April 2022, however, due to the Parliamentary timetable, a new target date of 1 July has been agreed for the new arrangements to take place.
Acing the acronyms: ICBs, ICSs and ICPs
The King’s Fund describes Integrated Care Systems (ICSs) as partnerships of commissioners and providers of NHS services, local authorities and local partners within a geographical area, whose key role will be to plan health and care services to meet local needs.
The ICS is made up of an Integrated Care Board (ICB) and an Integrated Care Partnership (ICP).
The ICB is responsible for NHS strategic planning, decisions and contract management for primary NHS services. The ICB is made up of a chair, chief executive and at least three other ‘ordinary members’ which must include one jointly-nominated by local NHS trusts, one nominated by local providers of primary care, and one by local authorities.
The ICP brings together partners to address public health and social care needs of the local population.
As the Health and Care Bill has progressed, the AOP has illustrated both the opportunities that the reforms could create for the profession, as well as pointing out the pitfalls that need to be avoided.
In addition, optical bodies represented by the Optometric Fees Negotiating Committee (OFNC) have joined forces with other primary care bodies to call for the new structures to ensure that primary care has a voice, urging the Government to commit to including formalised roles for primary care in ICPs.
OT spoke to two members of the profession to find out their views on what the new structures outlined in the Health and Care Bill could mean for optometrists.
Changes in commissioningThe biggest change to come will be the closing of CCGs and the transition to ICBs as the primary commissioners of services beyond sight testing – with the NHS confirming in December 2021 that General Ophthalmic Services will remain a nationally-agreed contract.
Chief executive officer at the Local Optical Committee Support Unit (LOCSU), Richard Whittington, explained that as they cover broader geographies, ICBs and ICSs could present an opportunity in the commissioning of future services: “CCGs were always population-based organisations and there were a lot of them, which meant that with everything over and above sight testing – such as CUES, cataracts and glaucoma-type services – there was always a fragmentation of commissioning.”
“We have a consistently nationally-contracted sight testing service, and what we’ve always striven for is something that was broadly equivalent in extended services so that, wherever you are as a patient, you are able to access a consistent level of care. I think there is a better chance of that with an ICS than there is a CCG,” he continued.
If done correctly and if we can get the recognition that I think we deserve, then there is an opportunity
Dharmesh Patel, chief executive officer of Primary Eyecare Services, and chair of the Greater Manchester Optometry Provider Board, told OT: “I think I would agree with the sector’s response that, overall, the development of ICSs is positive.”
Patel, who is also a board director of the AOP, agreed that historically, the large number of CCGs has meant “an enormous amount of variation” in commissioned services, sharing: “For practices on borders, or locums who work across borders, this means getting your head around which area you are in – and that shouldn’t have to be what a clinician has to worry about. They are here to look after the patient.”
“Anything that we can do to scale up that commissioning, so that it’s more consistent over a larger geographic footprint, is welcomed,” he said.
The issue of representation, and ensuring that optometry has a voice within the new structures, is also a key discussion around the reforms.
“As the Bill progresses there needs to be a recognition that when we talk about representation at an ICB level, we don’t mean GP representation as a proxy for primary care representation,” Whittington explained, “and this is something we are working on.”
This means ensuring that there is a mechanism by which optometry issues can be identified within the new structures at the “same level of emphasis as there is for GPs,” he continued. “As LOCSU, my view would be that we need to ensure that the LOCs, as the representative bodies of optical practice contractors and performers locally, are recognised within those structures.”
Identifying the potential opportunities of the new structures, Patel shared: “I think we hope for a greater recognition of wider primary care and optometry.”
This has had its challenges, he explained, commenting that “it wasn’t very clear how you could engage… thus the case made by the AOP and other organisations for the membership of boards to be more open and enable more people to be there, especially in terms of a primary care perspective where we sit.’”
I think we need to see that greater clarity on the role of primary care and its voice in the system.
Reverting to general practitioners as a representative of primary care runs the risk of being “a little short-sighted” Patel suggested. Though recognising that “you can’t have everybody on every board,” he felt: “we need to have a strong voice.”
Considering what might be needed, or what he would like to see as the Bill passes through the amendment stages, he said, “I think we need to see that greater clarity on the role of primary care and its voice in the system.”
The professionals felt that the three month delay in the transition may not have a significant material impact for optometry, and having a few extra months to prepare is not necessarily a bad thing. There are areas that both intend to closely observe, however.
Patel said: “Whenever the transition is, what we shouldn’t see is any decommissioning, we shouldn’t see any funding flows get confused, and we need to ensure that continuity of care continues.”
“There are several aspects to the transition: stability and continuity, and then transformation. I think we need to make sure we get the first one right. The second point is then around what the opportunity through the ICS is for optometry,” he added.
Whittington highlighted that one potential concern could be that delay breeds uncertainty: “The risk is that, with any reform process, the people who are working within those structures are working under a level of uncertainty.”
This can mean commissioners delay or defer a decision, “because they are waiting to see what the new structure is, and to see how it’s going to evolve.”
The opportunity exists now, and I think the opportunity will continue to exist in the new structures
For LOCSU, Whittington said, a focus will be on helping LOCs to prepare with “what we know… what we think the new structures are going to look like, and for what we think they are going to be like to work within, but to be flexible enough to recognise that they may change at any point.”
Reflecting on the changes, Whittington shared: “If done correctly and if we can get the recognition that I think we deserve, then there is an opportunity.”
Describing the opportunities for optometry in commissioning, Whittington told OT: “We are working through the National Eye Care Recovery & Transformation Programme and that is looking at recovery post-pandemic, but I think there’s a recognition that acute services and hospital services cannot continue to deliver all of the activity they currently are.
“Primary care can deliver additional activity. So the shift away from hospital care and into primary care is an opportunity to also drive the commissioning,” and this could theoretically be easier to do within the ICS, Whittington suggested.
There is a “definite desire” to see how Optometry First – a clinical model emphasising the role of primary eye care practitioners in first contact eye care – could operate in different localities, Whittington explained, adding: “We’ve got the beginnings of Optometry First beginning to take root.”
Looking beyond the changing structures and plans for reform, however, Whittington commented: “Irrespective of the commissioning changes, it’s about continuing to make the case for primary care to be the first port of call for eye issues, and to be able to take on additional responsibility for managing patients close to their homes within optical practice.
“The opportunity exists now, and I think the opportunity will continue to exist in the new structures.”
This month (January 2022) the AOP, as part of the OFNC, joined with representative bodies across primary care to call for representation in the new commissioning structures. Read more about this here.
Richard’s key takeaway
“The NHS is like an organism – it continues to evolve and change – and we always have to be flexible enough to move with the changes as they occur. The shift from CCGs to ICSs is a big shift, there is no doubt about that, but it brings with it opportunities.
“What we have to do is maximise the opportunities, whilst minimising risk. The best way to do that is to work together and work transparently.
“From LOCSU’s perspective, we’ll be working across LOCs and they will be working with one another perhaps more than they have previously. This is to engage with the process so that we’re in the best position to take advantage of the opportunities and be mindful of the risks, but not fearful of them. There is an opportunity and we’ve got to try and grasp it through the work of the National Eye Care Recovery and Transformation Programme.”