Care in the community
From a pioneering glaucoma service to the roll out of electronic referrals, OT explores how extended care is finding a home on the High Street
Under the shadow of the Bolton Town Hall clocktower, pigeons use a bronze statue of a former mayor and textile machinery manufacturer as a vantage point.
In the heart of Bolton, where the history of the area forms a backdrop to the bustle of everyday life, a quiet revolution is underfoot.
Specsavers Victoria Square is part of a group of practices that have helped to cut waiting times by a third following the roll out of a glaucoma enhanced referral service (GERS).
Optometrist and practice director, Matthew Thornton, explained to OT that patients were waiting 72 weeks for a routine glaucoma referral when waiting times were at their peak.
“It is anxiety inducing for the patients. Referrals were steadily building because of pressures linked to the pandemic,” he said.
The challenge of lengthy waiting lists – and the risk of avoidable sight loss posed as a result – is one that hospital trusts across the UK are grappling with.
Ophthalmology is the busiest outpatient specialty within the NHS, while glaucoma accounts for around one in five outpatient appointments.
In Bolton, in an effort to reduce waiting times, optometrists who see a patient with suspect glaucoma refer the patient to a GERS practice rather than secondary care.
“It is a triaging type of appointment – it reduces false positive referrals and takes the strain off the hospital service,” Thornton explained.
Roughly half (48%) of the 382 patients seen through GERS since it was introduced in October 2022 have been discharged back to the community.
The waiting list for routine glaucoma referrals has dropped below 40 weeks during that period.
“The fact that we are making a tangible difference to the hospital waiting time is exceptionally rewarding,” Thornton said.
“These initiatives raise the awareness among the general public of what optometry can deliver,” he highlighted.
The vast majority of patients receive their enhanced case finding appointment at a GERS practice within a month – an improvement on previous waiting times that meant optometrists would sometimes see a patient again for a routine appointment before they were seen in secondary care.
“The fact that we are making a tangible difference to the hospital waiting time is exceptionally rewarding
Thornton shared that as well as improving patient care, the service helps to add variety to the working day of optometrists within his practices.
“I know optometrists enjoy the GERS clinics because it gives them a day where they can do something different,” Thornton emphasised.
“A change is better than a rest, as they say,” he said.
The service is commissioned by the NHS Greater Manchester integrated care board and provided through Primary Eyecare.
In the context of an ageing population and workforce shortages within ophthalmology, Thornton believes that offering extended services within optometry will be key.
“Care close to home is what we need to do as a country. We don’t want people going into the hospital unnecessarily, especially when there are lots of people who are qualified in the community,” Thornton emphasised.
All optometrists involved in GERS are required to complete the College of Optometrists professional certificate in glaucoma.
The link between glaucoma and deprivationIn March this year, researchers from the University of Edinburgh and Princess Alexandra Eye Pavilion published a paper in Eye examining the relationship between socioeconomic deprivation and the severity of glaucoma at diagnosis.
Optometrist and study co-author, Fiona Buckmaster, shared with OT that she was interested in understanding what health inequalities exist in Scotland.
“In Scotland, the cost of eye examinations has been removed since 2006 but does that actually mean that people access eye care equally?” she asked.
Buckmaster added that in Scotland the spread of practices is relatively equal across different levels of socioeconomic deprivation – which is not the case in other parts of the UK.
Following the introduction of free eye examinations in 2006, Buckmaster highlighted that there was general uptick in the number of people receiving eye examinations in Scotland.
“However, the biggest increase has been in the most affluent populations. The uptake of eye examinations is still lower among those from low socioeconomic backgrounds,” she said.
The Eye study found that among the 472 patients referred to Princess Alexandra Eye Pavilion, glaucoma severity at diagnosis was worse among patients living in an area of socioeconomic deprivation. A disproportionate number of referrals came from wealthier suburbs.
“If glaucoma theoretically affects everyone equally, we should have 20% of our referrals from each quintile of deprivation. But that is not the case – over a third of our patients were from the most affluent areas. Only 4% of referrals were from the most deprived areas,” Buckmaster explained.
“There is a bigger story of how much pathology is going undiagnosed in the community,” she added.
As a disease that can be symptomless until an advanced stage, there is a direct relationship between how early glaucoma is diagnosed and how frequently a patient attends eye examinations.
Buckmaster shared that while the direct cost of an eye examination has been removed in Scotland, there are still real and perceived costs connected with attending a sight test.
There is a bigger story of how much pathology is going undiagnosed in the community
Patients may need to take time off work to attend an appointment – which represents a loss of earnings, particularly for workers on zero-hour contracts – and cover transport costs.
“People might assume that by going to an optometry practice you have to buy glasses or they will be pressured,” she said.
In General Optical Council research exploring the public perception of optometrists, among patients who felt uncomfortable attending an optometry practice, close to one in five (18%) identified pressure to buy glasses or contact lenses as the source of their unease.
Buckmaster shared that from her experience working as an optometrist in both affluent and high deprivation areas, access to eye care is generally symptom-led in areas of socioeconomic deprivation.
“Especially now with the cost of living – you’re worried about paying your rent and your heating bill – getting a routine eye examination when you have no problems is not really at the top of your to do list,” she said.
She observed that identifying glaucoma early is about the core role that optometrists play in preserving a patient’s vision over their lifetime.
“If someone comes in after not having a sight test for 20 years and they have advanced glaucoma, your heart just sinks. Once the damage is done, it is done,” Buckmaster said.
The focus for optometrists should be on making their practices as accessible as possible. This could involve having extended opening hours so patients can attend without taking time off work or being mindful of the messages conveyed by practice marketing.
“Spectacle sales are what keeps the lights on – it is a necessary part of keeping the optometry practice running – but we need to balance that messaging with our healthcare role,” she said.
“We need to make practices an atmosphere where people feel welcomed and looked after,” Buckmaster emphasised.
Seeing a child who has failed school screening can present opportunities to check whether the rest of the family is receiving eye care.
“This might be the first person who has had a sight test in the family for a long time,” Buckmaster shared.
Welsh optometrists to certify low visionA milestone moment occurred at the end of June when optometrists in Wales took on a task that has previously only been the domain of ophthalmologists in the UK.
Optometrists with both Eye Health Examinations Wales and Low Vision Service Wales accreditation can now certify vision impairment for patients with bilateral dry age-related macular degeneration.
In 2020, researchers from Cardiff University published a paper in Eye exploring the level of consensus between ophthalmologists and optometrists in identifying patients eligible for low vision certification.
They found comparable agreement between the decisions of ophthalmologists and optometrists – and this was particularly marked in the case of patients with bilateral dry age-related macular degeneration (AMD).
“The study that we did provided some evidence to support the ability of low vision optometrists to do this task,” study co-author, Dr Jennifer Acton, shared with OT.
As well as providing care closer to home for patients, the change permitting optometrists to certify vision impairment will ease some of the pressure on the hospital eye service.
“We know at the moment we have 57 consultant ophthalmologists across all of Wales,” study co-author, Rebecca Bartlett, highlighted.
“Before the change, they were the only people who can perform low vision certification. They were also the only people who can perform complex surgery – they are needed in other places,” Bartlett emphasised.
She shared that at present there can be long waits for low vision certification in Wales, with waiting times varying across the country.
There are currently 200 optometrists in Wales who are eligible to provide certification now that the pathway has rolled out.
“There will be a massive increase in access which will hopefully result in more timely certification and access to services. It also frees up the consultants to do what only they can do in secondary care,” Bartlett shared.
For optometrists, Bartlett highlighted that the changes enable them to provide continuous care to patients who they previously would have needed to refer to secondary care.
“Sometimes secondary care acted as a barrier to certification. Practitioners will see that they are caring in a more rounded way for patients. They can support them throughout the process of sight loss, not just at certain points,” she said.
Acton highlighted that the certificate of vision impairment can act as a gateway to services and support.
“It is around connecting patients with the services that they need as quickly as possible. We know that there is a worryingly high number of patients who may be eligible for certification but have not received it. We are working towards closing that gap,” Acton shared.
The benefits of low vision certificationOptometrist and Royal National Institute of Blind people eye health lead, Louise Gow, highlighted that having a certificate of vision impairment (CVI) provides practical and financial benefits to a patient – such as a reduced rate television licence, blue badge, or being able to take a companion into the cinema.
While those without a CVI are still eligible for support services, the CVI reduces the administrative burden on someone when accessing services.
“You don’t have to give all your medical details to a complete stranger. You have the evidence there and then,” she said.
There is also a broader social benefit in narrowing the gap between those who are eligible for CVI and those who have applied for it.
“It makes it easier to understand the number of people in society who might need additional support. That means we can plan services,” Gow shared.
Gow would like to see optometrists with low vision qualifications play a greater role in CVI.
She emphasised that freeing up appointments within the hospital eye service reduces the number of patients who experience avoidable sight loss.
“It is frustrating that patients who have been discharged from hospital with stable eye conditions are being referred back into the hospital in order to be registered because they have to see a consultant,” she said.
Gow added that being seen by an optometrist in the community has the potential to be a better experience for the patient.
“They will have an appointment with someone who will have the time to talk. They are more likely to make an informed decision,” she said.
Holistic careResearch published in Eye in April explored the experiences of people with sight loss around low vision certification and registration.
Professor Shahina Pardhan, of Anglia Ruskin University, shared with OT that there was confusion among the 17 patients who were interviewed about the certification and registration processes.
Optometrists need to start thinking about the person rather than a pair of eyes
“Some patients think that when they are certified they will automatically get support from social services. They fall through the cracks because they haven’t been registered,” she shared.
Pardhan noted that the research also found that optometrists had a tendency not to engage with certification and registration – particularly if a patient is under the care of the hospital.
“They think that they cannot meddle – but this is not about meddling, it is about signposting the patient to support that they might benefit from,” she said.
Pardhan encouraged optometrists to play a proactive role in caring for their patients. In practical terms, this could mean having a list of local charities in the consulting room.
“Optometrists need to start thinking about the person rather than a pair of eyes,” she emphasised.
“What I would like all optometrists to do is spend ten minutes with their eyes closed and find out what the world feels like. That is what your patient will be going through – what sort of support would you need?” she said.
The push towards connectivity
Electronic referrals are a key component in enabling more clinical care to be delivered close to home by optometrists.
Streamlined communication between optometry practices and secondary care has the potential to speed up the referral process, improve the quality of referrals and provide an avenue for referral feedback.
NHS guidance on priorities and operational planning for 2023-2024 states that by September 2023 systems should be in place to enable direct referral pathways between optometry and ophthalmology.
To view the full ICB responses, see the table at the bottom of OT's July 2023 article on electronic referrals.
In Greater Manchester and Essex, the majority of practices have access to an electronic referral system and are actively using it.
There are also several areas – including Frimley, North West London and Shropshire, Telford and Wrekin – where no electronic referral pathway is in place.
As the September deadline for direct referrals approaches, optometry practices in Bristol, North Somerset and South Gloucestershire were still required to send referrals to a GP practice for onward referral.
Where electronic referral systems are available, not all practices have made use of the system because of integration challenges with practice management software.
There is also a disparity between practices that offer extended services – such as minor eye conditions services (MECS) and the COVID-19 urgent eyecare service (CUES) – and those that do not.
Across the country, practices that offer extended services were more likely to be able to refer directly to secondary care using an electronic referral system.
“They were sending the letters back saying ‘Please use the online system,’ but we didn’t have the system,” optometrist and Bradford Local Optical Committee electronic referral system lead, Jenny Capozio, explained.
“It was quite stressful at times. We were wondering what the alternative was,” Capozio added.
An extension was negotiated with the GP practices, enabling optometry practices to continue to post referrals until they had access to the EyeV electronic referral system.
Now all practices in the Bradford area – except for four dispensing-only practices – are using EyeV for referrals.
Capozio believes that the new system will save time once initial integration challenges have been resolved.
The previous method of posting referrals to a GP practice created the risk of unnecessary delays and concerns about whether the referral had been received.
“There were a percentage of letters that didn’t get there,” Capozio said.
“The advantage with the EyeV system is that the referral automatically goes on a tracking board and shows you it has been received at the relevant location,” she said.
Rather than printing out images that would then be scanned by a GP practice – further losing resolution – EyeV enables optometrists to upload images directly to the referral.
“You can share what you are finding. Previously the technology we had in practice wasn’t supported by the system we used for referrals,” Capozio said.
Optometrist and fellow Bradford LOC member, Stewart Mitchell, also identified the ability to share retinal images, optical coherence tomography scans and topography data as an advantage of EyeV.
“This adds value to a referral. It is possible to generate a referral directly from your PMS,” he said.
Mitchell added that the system remains a work in progress. Initially, in January, only routine referrals were accepted. This was followed by wet AMD and cataract referrals.
He shared that EyeV have generally been responsive to issues that have occurred.
“EyeV also runs webinars to showcase the system and to address problems,” he said.
Optometrist, Dharmesh Patel, is a practice director of Dixon Optometrists in Stockport. He is also the chief executive officer of Primary Eyecare Services, which has been influential in the roll out of the Opera electronic referral system.
Patel shared that there is room for improvement in the roll out of electronic referral systems.
“For me, the focus should very much be around minimising double entry, getting feedback and having consistency across the country,” he said.
Patel observed that variation in electronic referral systems creates challenges for optometry practices that sit on the border between areas that use difference processes, as well as for locum optometrists.
Within Opera, this allows for certain mandatory fields to be completed before a referral is sent.
“It ensures that at least X, Y, Z information is there. You are reducing the chances of a referral coming to hospital with key pieces of information missing,” he said.
Of the 108,000 referrals sent through Opera in Greater Manchester, Cheshire, Merseyside and Lancashire in the past year, 16% contained attachments or images.
“You start to have more information with a referral which can only benefit patients,” Patel emphasised.
Optometrist and Essex LOC secretary, Emma Spofforth, helped with the roll out of Opera in Southend.
Spofforth shared that the system has now been live for over a year. During that time, there has been a 30% reduction in referrals to Southend Hospital.
Spofforth attributes the drop in referrals to both the roll out of an electronic system and having a single point of access where suitable referrals can be redirected to an optometry practice offering extended services.
“It is the two things combined. If you have lots of paper referrals, it is very difficult to send those back to a community provider. If it is all electronic, it is only the press of a button and those referrals can easily be redirected,” she said.
Her hope for the future is that the ability to share advice and guidance will be incorporated into the system.
“It would be great to have two-way communication with an ophthalmologist to determine if a patient actually needs referring,” Spofforth shared.
The importance of referral feedback
When Professor Bruce Evans attempts to describe the problem with referral replies at present, he asks me to step into the shoes of an alien observer.
This is a system where historically a referral letter would be sent to a GP and then relayed to the hospital, with the optometrist potentially relying on the patient to provide information about whether they had been seen and what the outcome of a hospital appointment was.
“The fact that we have a bizarre system where the reply goes to the GP who didn’t make the referral is just ridiculous,” Evans shared.
“You need to look at it with fresh eyes, and when you do, you think ‘we shouldn’t be where we are’,” he emphasised.
A paper published in Ophthalmic and Physiological Optics by Krystynne Harvey et al in February last year found that the referring optometrist remained unaware of the outcome of their referral in 73% of cases.
Evans believes that the implementation of electronic referral systems presents an opportunity to increase reply rates from secondary care. Evans argues that replies reduce unnecessary re-referrals and improves the quality of referrals.
“When I think about the barriers to replies, I do think there is an acceptance among our profession now that we don’t get replies. We need to change our mindset to one where we say it is not acceptable,” he shared.
“As a profession I would like to see us become more assertive and say, ‘We are only going to adopt the platform, if you assure us that we will receive automatic replies’,” Professor Evans shared.