In discussion: preventable sight loss

A Westminster debate saw MPs discuss the issue of preventable sight loss, NHS waiting lists and the role of independent providers

Big Ben is pictured around the curve of a line of buildings, old fashioned street lamps and trees
Pixabay/Matthew Browne

MPs brought eye care into focus as the topic of two debates in Westminster at the end of April – with particular attention on the role of community optometry.

On 30 April, Jim Shannon, MP for Strangford, Northern Ireland, brought a debate on the topic of Glaucoma and community optometry, while Margaret Greenwood, MP for Wirral West, brought up the issue of Preventable sight loss.

OT reports on the discussions in the second of a two-part series on the debates. Read a report on the first debate, here.

Preventable sight loss  

Margaret Greenwood, MP for Wirral West, brought a debate to Westminster on the issue of preventable sight loss.

Opening the debate, she asked MPs to consider how they might feel were they to lose their sight, and what affect it could have on their lives.

Greenwood pointed out that the number of patients on NHS waiting lists has reached more than 600,000, while a Royal College of Ophthalmologists survey revealed only 25% of NHS ophthalmology departments felt able to meet patient need.

The MP referenced research from the AOP which found 551 instances where patients had lost their sight because of delayed appointments since 2019.

The independent sector and ophthalmology

Greenwood discussed the growth of the independent sector, questioning the potential impact of the increased use of private sector provision on eye care.

The independent sector delivers almost 60% of NHS-funded cataract procedures, more than double than before the pandemic.

While this has helped to reduce cataract waiting lists, the Royal College of Ophthalmologists found 67% of NHS ophthalmology departments reported the impact of independent sector providers on patient care in the area as negative.

“It is important that we understand why,” Greenwood said, pointing out that departments are concerned around training opportunities for junior doctors, funding for NHS ophthalmology departments, and workforce.

Greenwood commented: “Royal National Institute of Blind People has said that the role of independent sector has been associated with significant challenges that pose an increasing risk to the sustainability of comprehensive eye care services in the NHS. I believe that the impact on many of our constituents could be, and is likely to be, devastating.”

A paper published by the Centre for Health and the Public Interest (CHPI) reported that, in the period between 2018–19 and 2022–23, the NHS paid the private sector around £700 million for cataract treatments, Greenwood shared.

The CHPI warned that the increased budget spent on cataract operations is likely to mean there are fewer resources available to treat other eye conditions, such as glaucoma and macular degeneration.

“Ophthalmologists have also told me that it is impacting capacity for the treatment of conditions such as cancer care, urgent treatment and the treatment of newborn babies,” Greenwood said.

CHPI reports that the rise in expenditure on cataract services has been accompanied by an increase in the number of private, for-profit clinics, which have been established to deliver NHS cataract services. The paper states that 78 new private, for-profit clinics have opened over the past five years.

Greenwood referenced concerns raised by Professor Ben Burton, president of the Royal College of Ophthalmologists, regarding some patients with mild cataracts receiving surgery at the expense of others, while unplanned commissioning is leading to the NHS losing “consultants, money and trainees to the private sector.”

Greenwood asked what discussions have been had with NHS England regarding the unplanned commissioning.

“In the not-too-distant future, we may face eye care deserts in some parts of the country, in much the same way as has happened with dentistry, with some people missing out on crucial treatment,” Greenwood cautioned.

She shared that use of the independent sector for ophthalmology has been more prevalent in some areas, with a regional analysis of trends published by the Royal College of Ophthalmologists finding that in 2021 the north-west of England had the highest proportion of NHS-funded cataract procedures delivered by independent providers, at 61%. The midlands, north-east, Yorkshire, and the south-west of England had figures over 50%.

Greenwood asked for clarification on comments made by Dame Andrea Leadsom, under-secretary of state for health and social care about the Government’s plans for specialty training places for ophthalmology, and asked what progress NHS England is making towards meeting its commitment, set out in the 2023 elective recovery taskforce implementation plan to track, monitor and evaluate the impact of the independent sector on long-term NHS capacity.

The Royal College of Ophthalmologists found 76% of NHS ophthalmology departments report not having enough consultants to meet patient need.

“There are concerns that the increase in NHS staff working in the independent sector on cataract provision is reducing the availability of training opportunities that enable NHS staff to train in more complex areas,” Greenwood said.

She continued: “That is potentially a time bomb for the future, and could mean that we will not have anywhere near enough staff trained to carry out work on treatment for conditions such as glaucoma and wet macular degeneration.”

“It is clear that we are facing a sight loss health emergency, and there is an urgent need for a national eye health strategy,” she added.

“It is clear that we are facing a sight loss health emergency, and there is an urgent need for a national eye health strategy”

Margaret Greenwood, MP for Wirral West

Greenwood highlighted calls to invest in a multidisciplinary eye care workforce, including ophthalmology training and digital solutions such as interoperable electronic patient records between optometry and ophthalmology, along with further development of integrated pathways for optometry.

She also emphasised the need for inclusivity in ophthalmology services, recognising the work of SeeAbility. The AOP has warned of the implications of potential budget cuts to the Special Schools Eye Care Service. Read the full story on OT.  

Eye care in the community

Kirsty Blackman, MP for Aberdeen North, shared a picture of approaches in Scotland, commending the work of optometrists and ophthalmologists and reflecting on her own experience of optic neuritis as an eight-year-old before regaining her sight entirely.

Blackman discussed the national ophthalmology workstream which brings together the views of those working in ophthalmology around areas such as cataract surgery.

She also referenced the pilot of the NHS glaucoma service which began in Glasgow and has been rolled out across Scotland.

“If someone can be treated in a primary care setting that they are used to, it is easier and better for everybody,” Blackman said, noting that it reduces some pressure on NHS services, and provides care closer to home for patients.

Preet Kaur Gill, MP for Birmingham Edgbaston, shared that the next Labour Government would seek to negotiate a deal with High Street optometrists for the delivery of out-patient care.

“Moving more care to the community will help to support those who are suffering sight loss, as will focusing on the provision of non-clinical community support to complement the work of community optometrists, ophthalmologists in hospitals and rehabilitation officers,” Gill said.

Referencing a 2014 study on the impact of the introduction of minor eye care services in Lewisham and Lambeth on ophthalmology hospital departments, which found GP referrals to hospital ophthalmology decreased by 75% in Lewisham and 30% in Lambeth, Gill said: “We know that delivering eye care in the community works.”

A 2022 dataset from Hereford showed 92% of referrals to eye casualty by GPs could have been seen by an optometrist via the minor eye care services and 83% of self-referrals could have been seen by MECS.

Gill pointed to data gathered from an OT Freedom of Information request finding that more than 550 patients have experienced sight loss since 2019 because of NHS delays, calling it “absolutely tragic.”

Preventing sight loss

Minister for Health and Secondary Care, Andrew Stephenson, responded to questions on behalf of the under-secretary of state in the Department of Health and Social Care, Dame Andrea Leadsom, emphasising that “preventing sight loss” remains a top priority. [Leadsom has since stepped down as MP for South Northamptonshire and will not stand in the General Election.]

“This debate is why the NHS invests more than £500 million every year on free eye tests for people on benefits, people over 60, and people at risk of serious conditions,” Stephenson said, sharing that more than 12 million NHS sight tests were delivered to these groups between 2022 and 2023.

Stephenson also noted work ongoing in preventing some of the causes of sight loss, including glaucoma and diabetic retinopathy.

Screening tests are offered to nearly four million patients with diabetes at least once every two years, he said, adding: “Since 2010, the number of adults between 16 and 64 who became visually impaired from diabetic retinopathy fell by almost a fifth.”

The approach has been commended by the World Health Organization, and in October, optical coherence tomography scans will be phased in as part of the screening programme.

“It is vital for patients who need to be in secondary care to have access to timely diagnosis and treatment,” Stephenson commented.

The number of patients waiting 78 weeks or longer for ophthalmology treatment has reduced by 96% since its peak, Stephenson said, acknowledging: “We know we have much further to go.”

NHS England’s transformation programme is funding seven projects across each Integrated Care System (ICS) area to test how improved IT links between primary and secondary care could enable virtual triage.

“These initiatives have shown promising results,” Stephenson said, pointing to a project in North Central London ICS, between community optometry and Moorfields Eye Hospital, which reduced triage time from 11 days to one.

NHS England is using the data from these projects to build the case for a wider roll-out.

Addressing challenges in ophthalmology  

Stephenson shared that training places for ophthalmologists have increased in 2023, along with improved training for existing staff, while funding is also supporting research in sight loss and treatments.

“Eye care services face challenges and we are taking decisive action to address them, both now and in the long term,” he said.

“Eye care services face challenges and we are taking decisive action to address them, both now and in the long term”

Andrew Stephenson, Minister for Health and Secondary Care

On the topic of independent sector provision in ophthalmology, Stephenson suggested that utilising the sector “enables us to fully realise our healthcare system’s capacity and to reduce the time that patients spend on waiting lists.”

Stephenson said the overall proportion of NHS England’s spend on independent sector providers has not increased significantly in recent years, sharing: “In 2013–14 6.1% of total health spending was spent on the purchase of healthcare from independent sector providers; in 2022–23 the proportion was 6.5%.”

“While recognising that there are always challenges with the use of the independent sector, it is not in any way a privatisation of the NHS,” he added.

Concluding the debate, Greenwood asked the Minister for Health and Secondary Care to “look at the practical outcomes” of using the independent sector in ophthalmology.

She commented: “We need a national eye health strategy to preserve vision and prevent sight loss as a matter of urgency. We need a comprehensive and universal national health service that is there for us all when we need it for eye care and all other areas of health.”