Optegra at 15: “The working relationship we have with our local optometrists is so important”

As Optegra marks 15 years in the UK, OT heard from Richard Armitage, NHS director for the hospital group, on what has changed, supporting the NHS, and the life-changing effects of cataract surgery

How has Optegra changed in the 15 years since the business opened in the UK?

The business pre-pandemic was an almost entirely private A–Z ophthalmology offering. That served us in good stead for a number of years, but what was becoming increasingly apparent in 2019 was that we needed to focus on a few key specialities. Our CEO changed the business focus to high volume, NHS cataract work, and private vision correction. We made those decisions before the pandemic, but of course, that also dramatically changed the health landscape. We then became really well placed to help support the NHS as we came out of lockdown.

What changes has Optegra seen in the sector?

The biggest shift that we could demonstrate is that pre-pandemic, we were doing about 3000 NHS cataract surgeries. Last year, we did about 30,000. This year, we expect to do about 50,000.

A large part of that was driven by our determination to support the NHS and open new sites, but there has also been a shift in the ophthalmology market. Outsourcing has changed dramatically post-pandemic. We’re now in a world where about 50% of cataract surgery is delivered in the independent sector.

Outsourcing of high volume, low complexity work was coming, but as with a lot of things, it was accelerated by the pandemic. I think what that enabled was closer working. The partnership between the NHS and the independent sector has improved in the past three years.

The other big change that we’ve seen across healthcare more broadly, is looking differently at how you do what you do. With an increasing pressure on resources, and the need to deliver a greater volume of care, it’s important that clinicians are operating at the very top of their licences. If we look at how we used to deliver cataract pathways a few years ago, the consultant was involved in almost every step of that journey. We’ve standardised our pathway to enable the consultant to focus on doing the surgery, with the support of our optometrists in pre- and post-op checks plus consent. Our optometrists now play an increasingly important role in making sure that the patients are fully informed and consented, as well as working with community optometrists to support with post-op checks when convenient for the patient.

The working relationship we have with our local optometrists is so important to ensure that we get a seamless patient experience. The optometrists that work in our clinics are doing a lot of the work now that, four or five years ago, could have only been done by a doctor. This has helped our expansion of services.

Outsourcing of high volume, low complexity work was coming, but as with a lot of things, it was accelerated by the pandemic

Would Optegra look to expand further?

We’re not looking for growth at any cost. The growth has to come first and foremost from delivering the best standardised pathway to our patients. We believe that delivers the best clinical outcomes: the more standardised your care is, the safer it becomes, the better the outcomes.

Opening new sites comes secondary, but absolutely over the next few years Optegra will continue to focus efforts on working with the NHS to provide services in areas where there is an unmet demand. We have got several more openings planned in the next 12 months.

We’ll continue to look at areas where we see an unmet demand, with long waiting lists, or a prevalence of cataract. Or, where the cataract volume is disproportionately low to what you’d expect for the population, which often is an indication of a lack of supply and patients being unable to access services.

How is the balance of private and NHS service provision determined in a location? How does Optegra see its role in supporting the NHS going forward?

The private market remains a significant part of our business, offering vision correction as well as private cataract options. But when it comes to opening new locations, we’re very much NHS-first. If we see an opportunity in those facilities to offer vision correction or private cataract options, we would look at that. But first and foremost, the locations are around where can we best deliver NHS cataract services.

Looking beyond that, at how we want to continue to work with the NHS in the future, we will be looking at other sub-specialties with unmet need. We’ve got a fantastic age-related macular degeneration (AMD) offering up in Manchester and Yorkshire. It’s hugely important that AMD services can be delivered at speed and close to home, because it’s a very frequent patient visit. We are looking at where we can start to expand those services in the future. Glaucoma is also increasingly prevalent and massively underserved.

How are you working with local optometrists?

The community optometrist is the first and last touchpoint for our patients. The involvement of the optometrist in our pathway has certainly changed in the past couple of years. On the front end of the referral side, there has been a move within the sector towards greater pre-cataract refinement pathways in the community. This avoids the patient needing to be seen by their GP before being referred to a secondary care provider.

From the patient’s point of view, it’s quicker and easier. For the secondary care provider, we get patients that are very well pre-screened because the optometrists are educated on which patients are suitable for high volume, standalone clinics such as ours, versus which patients have more complex needs that need to go to the trust.

That has been a piece that the commissioners have worked to achieve, but it continues to vary across the country. Within the 42 integrated care boards (ICBs), some have still got rather traditional pathways that see patients being referred by their GP, which just seems incredibly wasteful of time. But increasingly, these referral routes are direct.

The community optometrist is the first and last touchpoint for our patients

At Optegra, our service promotions team meet with optometrists to make sure they’re aware of what we can offer, our suitability criteria, waiting times, and our clinical outcomes. The optometrist can then be having informed conversations with the patient about the choice of where they want to go.

I think one of the biggest changes has been the post-operative assessment, which is now done by the optometrist in the community almost everywhere. About 80% of our patients will go back to their optometrist for their post operative assessment, which has multiple benefits. It allows us to free up capacity to see more patients at the start of their journey and therefore helps bring down waiting times. It is great for the optometrist to see that patient back in the chair, providing a continuity of service, and there is some financial reward for doing that as well.

From the patient’s point of view, it means they don’t have to travel back to a hospital for an appointment. We’re relatively accessible, but popping to your local optometrist for your post-op is much more convenient than coming to hospital. Patients like the continuity of care of going back to their local optometrist. I think the post op has been quite transformative and that will continue to evolve over time.

In what ways does Optegra support clinical education?

We support our local optometrists through education. So far this year, we’ve hosted 50 CPD events for optometrists, online and face-to-face. It helps to be able to promote the offering that we have, but we also provide CPD for specialties we don't offer, so we’ll cover glaucoma, medical retina, oculoplastics – anything that the optometrist wants to help their education.

The training extends beyond the optometrist, as well. Along with other providers, we're working closely with a number of local trusts to try and develop junior doctor training. If half the cataract surgeries in the country are being done in the independent sector, then there is an obligation on us to help support the training of doctors for the future.

It’s early days but we’re soon to place our first trainee. There have been various logistical challenges and working between deaneries, trusts and ourselves is tricky to orchestrate. But we’re really excited that hopefully in the next few months, we’ll have our first junior doctor join us in our Guilford hospital in Surrey to develop their cataract surgical training in a high volume setting. Fast forward five years, hopefully there will be increasing number of cataract surgeons that can operate in a high volume setting, a level that is going to be required by every hospital, because the prevalence of cataract isn’t going away. As people grow older, we’re going to see more and more need for cataract surgery to be done in a slightly different way, and to do that you need highly skilled surgeons.

Where do you hope Optegra would be in another 15 years?

Our ambition remains to be the UK’s most recognised provider of focused eye services. Currently that is cataract. Do we see a world in which that changes? Yes. It’s hard to say where, because there have been huge advances in technology. If you look at what we’ve done in the past three years in moving to telemedicine, or the delivery of services through optometrists closer to home, it’s changing dramatically.

Technology is only going to accelerate the pace of change. There is talk about what artificial intelligence (AI) could do or the healthcare sector. We are exploring a number of areas where we can use AI and digital-first to help improve our patient experience.

In 15 years, the business will look a lot different to the way it does today. Will we still want to be giving the best outcomes to as many patients as possible in the areas that the NHS needs us? Yes, we will. Do I think it’s going to be supported by an almost unrecognisable amount of technology and digital support? I think it probably will. Hopefully Optegra can be at the forefront of a lot of that, and we will have a good few hundred thousand more happy patients.

Technology is only going to accelerate the pace of change

Is there a moment or development in Optegra’s 15 years in the UK that stands out to you?

One of the standouts has to be the pace at which our team adapted to the changes in early 2020. The business had already made some decisions around changes we wanted to make, but those things invariably can take a huge amount of time. Over 2020 we were dealing with the unknown of COVID-19 and we were also completely redesigning how we delivered care within our hospitals. We asked a lot of our teams to support us along that and believe in the process. Our teams are what made it happen and I’m really proud of that. We can almost forget, when we look at the business now, what was achieved in a short space of time. It’s credit to our team that we did that.

---

What are your reflections on the Government’s plans to expand the role of the independent healthcare sector in supporting the NHS? 

I think it’s important to recognise the work that the Government has been doing the past year. Reducing waiting lists has been a priority for Rishi Sunak and sadly that on paper hasn’t worked; the waiting lists have grown. What has happened, is that it’s not just a government policy that’s then not translated into reality at the shop floor. We’ve started to see the mechanics of the commissioning process and a willingness to engage with the independent sector in a way that we probably didn’t even six months ago.

Most of that has been a result of legislative and guidance changes that have supported the Government agenda. It isn’t consistent across all 42 ICBs but it’s getting better. I think there’s been a shift in recognising that there needs to be a genuine choice within providers. The offer of Trust A or Trust B, both of which have got waiting times of six months and both of which are 30 miles away, is not a realistic or suitable choice. We’ve got more providers able to operate either in the ophthalmic space or at the wider sector that can now offer genuine choice to patients. There’s more to do, but it feels like there’s a new era where this partnership approach is starting to be realised and I think that’s quite exciting.

Ophthalmology has been a great example of where independent sector providers can help support outsourcing and deliver a very different model of care that hopefully other specialties, be it orthopaedics, endoscopy, or gynaecology, can start to follow. The trust simply will not be able to deliver the work on their own, they need to work in partnership, and I think ophthalmology has set the standard of what good looks like.