Optometry in the new NHS structure

With integrated care systems established since 1 July, OT  asks: where we are now in the transition, what the changes have involved, and what comes next?

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July marked a new beginning for the NHS, with integrated care systems (ICS) across England becoming legal entities.

The overarching aim of the 2022 Health and Care Act, which was formalised earlier this year, has been to deliver care in a more ‘joined-up’ way and make it easier for organisations (such as local government, charities, primary care and NHS partners) to work together.

Established on a statutory basis on 1 July, ICSs are described as “partnerships of organisations that come together to plan and deliver joined up health and care services, and to improve the lives of people who live and work in their area.”

With the systems now in place and underway, OT sought to understand what the changes look like for optometry, if there are questions that are yet to be answered, and what the next steps are.

The transition: where are we now?

Zoe Richmond, clinical director for the Local Optical Committee Support Unit (LOCSU), outlined that, in the new system, the emphasis is on “collaboration rather than competition.”

This, and a general recognition of the importance of more care outside of the hospital setting, more integrated and preventative care, and a bigger role for primary care or non-acute care, “has the potential for greater optometrist involvement in end-to-end pathways.”

At a local level, or ‘place’ and ‘neighbourhood’ as it is now known, “optometry via local optical committees (LOCs) has the opportunity to work collaboratively with other sectors,” Richmond noted, adding that engaging with primary care networks (PCNs) will be important.

LOCSU has been preparing for the transition in a number of ways, including through regional forums along with NHS footprints, producing guidance documents and events, and supporting with engagement at system and place levels.

Training has also played a significant role in preparation, with training and induction delivered, all geared towards the new architecture.

Primary Eyecare Services (PES), which forms contracts to deliver NHS-funded eye care services through local optometry practices, has a presence in 29 of the 42 ICBs.

Describing the process of transitioning to the new structures, Dharmesh Patel, CEO of PES, told OT: “We are glad to be able to say that all of our contracts have transitioned to ICBs, with no service falling between the gaps.”

The process has been smooth, Patel shared, although he noted: “We’ve been advised to expect a few commissioning areas to have some very small delays, because of potential signing-off processes in the first month, but we’re expecting that to go back to usual within a month or so. That is something we’re watching very carefully to avoid problems for practices in terms of flows of payments.”

A number of geographical and boundary changes represented a possible challenge for PES. Glossop, which had been part of the Tameside and Glossop clinical commissioning group (CCG), and was due to form part of the Greater Manchester ICS, has instead become part of the Derbyshire system. Similarly, the West Birmingham area, which once was part of NHS Black Country and West Birmingham CCG, moved to be part of the structure in Birmingham and Solihull.

“We’ve had to put in additional changes to manage those,” Patel noted.

As the areas changed boundaries, a particular challenge was the risk of moving from a higher tariff area to a lower tariff area. Patel explained: “With the commissioners, we’ve managed to negotiate a position where the current tariffs they were being paid will continue for the coming year until there is a full review, which we’ll be doing collectively with LOC partners and commissioners. Levelling-up will be a key ambition.”

“We’ve got a clearer sense of what’s happening and what will happen in the coming days, weeks, and months ahead,” Patel said, suggesting that the next year will be one of transition, building on the formal establishment of ICSs.

Commissioning and the opportunities ahead

“Strategically, what we were really hoping for was a consolidation of contracts in those big ICB areas, so we would see those standardise and harmonise,” Patel said.

“I think what is clear to us is we will have a mixture of areas where in commissioning, the contract might sit with the ICB, but there will be variations or decisions made at what is now called ‘place,’” Patel explained. “PES has accepted that we will have place-based variation, although we’ll continue to make the case for ICB-level commissioning, as well as consistency and standardisation.”

The optometry sector at large, has been making the case for commissioning at scale “for a very long time,” Patel emphasised, and ICBs present an opportunity to do that.

“We need to see unwarranted variation removed and I believe we’re on the same page as commissioners in this regard,” Patel said. “However, the Government and NHS have been clear that the new architecture, especially in the larger ICBs, is very much place-based-up.”

There are some services, Patel acknowledged, that are performed in close collaboration with hospitals in a local area, such as glaucoma monitoring, but there is still the opportunity for this to be scaled up, “in terms of consistency of pathway and tariffs.”

“I think there are some elements we absolutely can scale up, standardise, harmonise, and then there are some elements that we may have to keep variable. I think we need to be flexible enough to be able to meet those needs,” he said.

LOCSU has previously highlighted the opportunities that the new systems could bring for the wider commissioning of extended services. Asked if these opportunities have become clearer since the establishment of ICSs, Richmond said: “The new systems undoubtedly allow for this. They offer the potential for scaled-up commissioning, but it’s still to be seen how or whether ICSs embrace this. The will must be there at all levels.”

NHS England’s National Eyecare Recovery and Transformation Programme has developed the Optometry First model, Richmond noted, “which gives the potential for maximising optometrists’ core competencies and optical practice infrastructure across a wholistic pathway, and across larger geographies than was the case under CCGs.”

Early adopters of Optometry First are live in three areas currently, Richmond shared, with the ambition to roll this out across England.

Consistent commissioning is “critical” for primary eye care, Richmond suggested, if it is to deliver the best outcomes and help to reduce health inequalities.

“The new system is designed to realise the Government and NHS’s objective of greater out-of-hospital care, a greater role for primary eye care in first contact care and monitoring, freeing up secondary capacity,” she continued. “This needs to happen, and if it does, and the potential is realised, this could help to alleviate waiting lists and reduce ophthalmology appointments at the Hospital Eye Service, of which ophthalmology has the most outpatient appointments of any specialism.”

However, a lot of challenges remain, Richmond explained: from IT and digital connectivity, to building on initial buy-in from secondary care to ensure that the primary care sector remains integral to the whole pathway, as well as a need to avoid reverting to old practices.

Representing optometry

Representation has been a key concern for the optometry sector, and broader primary care professions, in the run-up to the passing of the Health and Care Bill. Primary care bodies came together to call for primary care beyond general practice to have a voice in the new systems.

Has this been reflected in the new architecture? “Yes and no,” Richmond told OT. “Although each ICB will have a primary care rep, this has to be from general practice.”

Most GPs recognise that patients with ocular issues are best seen in primary eye care services, Richmond noted, but added, “optometry involvement in the new structures is variable.”

A key role for the LOCs going forward is to drive this involvement, Richmond explained: “There is an ongoing process of impressing upon the new structures the role and capability of primary eye care.”

Patel expressed disappointment that optometry has not been better represented within the new systems: “It was a shame that the commitment made in the Houses of Parliament for really clear representation of wider primary care – optometry, pharmacy, dentistry – hasn’t necessarily followed through consistently across the country.”

LOCs and others across the sector have been working with the GP-nominated primary care partners to make sure that there is a representative voice from optometry.

“One ray of light is that, in one or two ICBs, we have seen a non-GP appointed in a secondary, additional role alongside the GP,” Patel explained, with the Cheshire & Merseyside ICB appointing a pharmacist to a second additional primary care partner post.

A second observation about ICBs, Patel shared, is the presence of local authorities in some of the structures.

“It’s a new dynamic to which optometry has been historically less exposed, because we haven’t had to interact with local authorities for the care that we’ve delivered. There’s a whole group of additional people that we will need to work with and influence, to make sure they understand the challenges that we have,” Patel said.

He noted, however: “Local authorities really care about High Streets, and with optometry practices on the High Street, I think there are some real opportunities there.”

The next phase

Describing what comes next, Patel said: “For me, the aim that PES has is the same as the wider optometry sector, which is to have more care delivered in optical practices at an appropriate level of remuneration, that supports patients, the NHS and our practices.”

“The next phase is how we consistently scale up some of the great work we have across the country,” he added.

In addition to scaling up services that optometry is familiar with, is the question of how optometry supports hospital services with managing a larger proportion of follow-up care, Patel shared.

“Scaling up transformation to support the NHS backlogs and patient care has to be a big part of that, but the caveat of course being, doing that in a way that allows us to manage capacity demand in practice, and ensuring that it is appropriately remunerated – these have to be caveats that we take into consideration along that journey,” he said.

Richmond highlighted that the next steps are all about communication: continuing to engage “at all levels and work together,” along with “continuing to engage with LOCs, and LOCs in turn, to engage with new structures.”