Q&A: Zoe Richmond on Optometry First

LOCSU clinical director Zoe Richmond shares insight on a new model of providing eye care closer to home

trial frames
Getty/Luis Alvarez
A pioneering vision for delivering eye care is being delivered by hospitals and optometry practices in three ‘early adopter’ areas – Isle of Wight, Bassetlaw and Sefton.

Optometry First aims to provide convenience to patients and ease the burden on secondary care by broadening the scope of services provided by optical practices.

OT spoke with Local Optical Committee Support Unit clinical director, Zoe Richmond, for an update on how the new model is transforming care.

What is the vision behind Optometry First?

Optometry First is a comprehensive new care model. It is an ambitious model, delivering optimal first-contact care and continuity of care for local communities. My vision is for every optometrist and dispensing optician to be able to fully utilise their skills and the equipment available to them on the High Street to best meet patient needs and for patients to think, “optometry first” whatever their eye or sight concern.
Too often an optometrist may make a decision to refer because they are not commissioned to do anything further with that patient, even though they have the equipment and the skillset to refine the referral or manage the condition. This is disheartening for the clinician and inconvenient for the patient. We know that this adds to the pressures that our secondary care colleagues are facing.

It is about broadening the scope of care available within practice, by empowering the optometrist to make the clinical decisions based on the needs of the patients alone, offering further diagnostics and management or signposting to colleagues with more appropriate experience and specialist equipment. This will be supported by advice and guidance from peers with higher qualifications as well as consultant ophthalmologists in hospitals. We will broaden the scope of practice within primary care and enable the co-management of care. The patient comes to a familiar local setting but the scope of care is increased. It is more than a suite of care pathways – it is a change of culture.

What needs to be in place for this vision to become a reality?

There would need to be investment in primary eye care, appropriate commissioning, effective digital connectivity and routes to support workforce development. We would need to ensure that our professional competencies are better understood, with clinicians supported to work at the top of their licence. We would need to make sure that there is appropriate connectivity to enable safe advice and guidance and co-management of patients. Although the name Optometry First suggests that the care is delivered within the optometry practice, it is very much an integrated care model requiring adaptation across the whole care pathway. It requires changes within optometric practice and a new way of working across the hospital setting too.

Too often an optometrist may make a decision to refer because they are not commissioned to do anything further with that patient even though they have the equipment and the skillset to refine the referral or manage the condition


It is quite ambitious and it is not going to be delivered overnight. We need to think of where we want to get to in five years’ time and then consider what we need to put in place now to begin moving in that direction.

What progress has been made so far?

From 17 integrated care systems that expressed an interest, LOCSU and NHS England carefully selected three early adopters: Isle of Wight, Bassetlaw and Sefton. We are working intensively with the local optical committees, practices and the secondary care providers within each footprint. NHS England has presented the vision and asked the early adopters what it means to them and how they would go about implementing change.

It is very much the commissioners coming forward and saying ‘These are our pressure points – this is where we need some additional support. How do we work with optometry to address these particular issues?’ We are not coming forward with all the answers. We are co-designing this with local teams, building upon the principles of Optometry First.

All of the early adopters had successful COVID-19 Urgent Eyecare Services and were seeking to build on their success. We are working with three very different areas. When I say they were carefully selected, they weren’t cherry picked. We have not avoided the challenging situations.

Not by design but by coincidence and local selection processes, Primary Eye Care Services is the provider for all the early adopters. That gives us some advantages because it means that all of the data is being captured on the same system, in a consistent way. Although we have Optometry First in three different isolated areas, delivering different care pathways to meet local need, what we can do in time is pool all of the data.

NHS England has not provided financial support. They have looked to the local areas to find their own investment. Although I think it will take longer without new money in the system, it will provide a real world test and produce a sustainable model that is scalable.

What response have you had to Optometry First?

From a primary care point of view, we have had excellent engagement. This is the first time that we have had NHS England support for a comprehensive new model within optometry in England. There is an understanding from primary care that this has the potential to shape the future and help inform the blueprint for eye care transformation going forward.

We do need to recognise that it is not an easy time for optometry. Practices are still recovering from the impact of COVID-19. They are managing high rates of staff sickness and we still have heightened infection control procedures. At perhaps one of our most difficult times, optometrists are making space in their diaries and recognising that they are part of the solution to supporting eye care transformation.

It is a little more mixed in hospital settings. I can understand that because they have their heads down and they are trying to get through considerable backlogs. Their clinical teams are working as hard as they possibly can and don’t have protected time for transformation meeting with LOCs. Any transformation takes time and energy and doesn’t immediately deliver outcomes. However, they are absolutely engaging with this and recognise primary eye care as part of the solution.

Do you have any examples of how Optometry First has improved care?

Bassetlaw’s first priority was the children’s service, where they had incredibly long waiting times. Working with primary care, they put in place an audit and clinical triage of all the children’s referrals going into ophthalmology. As a result of that, they saw over half of those children who were sitting on the waiting list redirected into the newly commissioned Optometry First service for assessment and management by an optometrist.

A lot of these children were referred in by health visitors, others have come through the vision screening programme. There were four and five year olds sitting on the waiting list for up to two years. Most of them had not even had a refraction.

The audit for children saw 56% of the waiting list redirected to optometry. They then completed an audit of the adult waiting list, which saw 23% of referrals redirected to the Optometry First service. If we could scale it up across England, that would have a significant impact.

The expectation is that most people will be fully managed within primary care optometry. But even if they are not, and some of them do ultimately need to be seen by an ophthalmologist, through the Optometry First service we will provide a fully informed referral with a clearly identified level of referral urgency.