“All levels of healthcare need to upskill to broaden the way that healthcare is delivered”

Chief officer of Primary Eyecare Services, Dharmesh Patel, speaks to OT  about his belief that meaningful change is coming as the NHS in England recognises the value of community optometry for patients – and why the sector must seize the opportunity now

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What are your thoughts on the state of the NHS in England today and the argument that over-referrals are placing undue strain on secondary care?

It is important to focus on the context and the environment. Ophthalmology is the number one cause of attendance at hospitals. We have hospitals struggling to handle demand, there is a lack of capacity, and patients are experiencing delays.

I am aware there is a perception that optometry is responsible for part of the problem because of so-called ‘unnecessary referrals.’ That is an inaccurate view. Our sector carries out a massive number of sight tests – in the order of 12 to 13 million per year. In light of the episodes of care that take place every day, the number of referrals is small. The demand on the service due to an ageing population, the increasing technology available in practice, and greater clinical awareness among optometrists, all mean there will be more referrals.

The big problem for hospitals, and for ophthalmology more generally, is that ageing patients come into the system and then stay in the system for a long time. For the NHS in England, the scale of the challenge is massive.

The challenges we face are significant. Should we be optimistic that change can come?

Of course, there are challenges, be it financial, reputational, and operational. But, from my perspective, the stepping-stones for greater primary care involvement are there. NHS England and the sector need to grab this with two hands – that’s my personal view. To achieve this, I think the sector does need a single unified voice. Ultimately, the NHS will not speak to any sector without one.

I think a model of care that does not utilise optical practices remains a concern. It is hard to perceive how it could be done, but that does not mean it is not possible – be it through technology or other professional groups. Therefore, local optical committees (LOCs), the Local Optical Committee Support Unit (LOCSU), the optical bodies, the corporates and the independents all need to have a consistent approach.

My view is that great strides have been made already with the NHS in England through local and collaborative commissioning via Primary Eyecare Companies. Whether it is in referral filtering type services, or minor eye condition services (MECS), or managing patients for post-operative follow-ups, there has been huge progress in terms of volume and impact around the country. This is while appreciating the substantive opportunities and scale yet to be achieved.

An example of the pace of change is in primary care eye health services, the vast majority of which are delivered through optical practices. Commissioners and hospitals are waking up to this shift, which is really important as they need to engage with primary care optometry. Two or three years ago that discussion was very different. However, a significant number of commissioners still do not really engage with primary care optometry.

Is the fractured nature of commissioning across England a key concern?

Fractured commissioning results in complexity for primary care practices, and a poorer patient experience. What needs to happen is the scaling up of commissioning over large geographical footprints, ideally nationally, so that we have consistency across regions and an equality of offering for patients.

From an optometry perspective, we have no consistency in what is delivered. There are over 100 ophthalmology hospitals and 6,000 optical practices; but 191 clinical commissioning groups (CCGs) commission their own pathways or in some cases do not commission them at all. Therefore, we have a postcode lottery of what is available for patients.

LOCSU has made great strides through the primary eyecare companies  to commission additional pathways that optical practices can deliver, but this is neither consistent nor universal yet.

Another issue, and one that the AOP also raises, is the lack of connectivity for optometry into the NHS’ electronic systems. This is a real barrier to great communication between primary care and secondary care. Changing this situation will improve the quality of referrals and feedback.

To make this change requires strategic will from the NHS. From what I hear, this is coming – and we hope to hear an announcement from NHS England soon.

Is there sufficient appetite and momentum to drive the change you describe in England?

Look at the NHS outpatient transformation programme within ophthalmology. The fact that this is a priority is a very good direction of travel for the NHS in England. We are seeing the importance of primary care being recognised.

Seeing the progress in commissioning is also good, and I think there is a need for the outpatient programme to be done at scale and pace. If we don’t achieve that, we won’t be able to be as ambitious about transformation. We are hearing the right things from key NHS commissioners and leaders – but it needs to engage with primary care much more substantively to enable that to happen and really look at the situation in an innovative and open-minded way. That could include General Ophthalmic Services (GOS) reform or something in parallel.

Ultimately, the situation we are in today is due to a lack of consistent NHS action over many decades. So, the NHS in England needs to move at pace – while being be careful to work with the sector for the benefit of patients and practices.

Why is it important for OT readers to engage in this debate, and what can be done on the ground to support the change?

When we think about changes in technology, deregulation and so on, the reality is that the roles of optometrists are going to need to change for the sustainability of the model of the sector in the future. It is my opinion that this includes expansion into greater clinical work including NHS services.

My advice to optometrists is to engage with their LOC, get involved with the services in their area, and deliver them to a high standard. As a sector, making the services work makes the case to the NHS in England for this approach to be done in a consistent way.

I recognise the challenges that practices have on the ground day-to-day. My own practice, for example, sits on three different borders with three different pathways, and we spend time just working out where the patient is from and which pathway they need to follow.

I appreciate that individual practices cannot enact change alone. But I believe NHS care is going to be fundamental to the future of optical practices. There may be challenges to what the financial package will look like, as well as what additional clinical work we do, but in my view that it is part of the mix of discussions needed to keep optical practices viable as businesses in the future. It is a balance that we have to get right.

How important is it to have a unified skill set within the profession?

It has always been my view that optometrists qualify at a high level but are under-utilised in practice day-to-day. We need to utilise the skills we have already. And I think that we will always have optometrists with higher qualifications and those with specialist areas of expertise.

Everyone in optometry will need to upskill somewhat, but this is not limited to optometry – all levels of healthcare need to upskill to broaden the way that healthcare is delivered.

The AOP will be launching the AOP long term plan for optometry in 2020. Why is this needed?

I think the AOP long term plan is really important. It has been missing from the sector for a very long time and it is important for the whole sector to buy into.

What it will do is to lay out what are the risks and challenges of the future – and how we can solve them. And a lot of these solutions are about the greater utilisation of primary care, and how that aligns to the NHS Long Term Plan.

A lot of people get very heated about the fact neither ‘optometry’ nor ‘eyes’ appeared in the NHS plan. While sight loss is emotive, actual sight loss is rare. That is why cancer and cardiovascular disease are going to be at the top of the list every time.

However, the NHS plan has clear objectives: delivering care closer to home; out-of-hospital care; and population health. Optometry and eye care services have something to add of value in every single one of those areas, and the AOP long term plan for optometry will set this out.

I would argue that we also need to ask ourselves: ‘what is optometry’s contribution to the health of the population beyond eyes?’ That is a focus of the NHS, and that’s where healthy living optical practices have an opportunity to develop. While this angle for optometry is not the priority while the focus is on ophthalmology, the need remains, as does the requirement to support primary care partners. Optometrists are in prime position in the community – we have a patient sat in the practice for 15 to 30 minutes, and we could and often do use that moment of opportunity to open up a conversation about weight, diabetes, smoking, and so on. It is time for optometry to change its message with the NHS. When we don’t talk about eyes, the NHS listens because it’s focus is on how to improve population health.

What can be achieved with NHS England in 2020? And what does success look like for the sector?

I am optimistic that actual change on the ground will take place, based on three factors. First, the national outpatient transformation programme has very high ambitions: to reduce all hospital outpatient appointments by one third. The target date has been set for three to five years. Second, ophthalmology has been recognised as an NHS priority within the NHS Elective Care Outpatient Transformation Programme and is now first in the NHS programme of works. It my belief that the NHS will need to show impact and change in 2020 to 2021. Third, the number of CCGs is reducing from 195 to 132 in 2020, and next year should drop to 80 to 90.

This means there is a responsibility of our sector to capitalise on the situation. We need to offer the solutions, as outlined in the NHS Long Term Plan, to enact change. And I think that those changes will have to be deployed in 2020-21 or shortly after that. It is my view that we must seek a change in the coming year, or the NHS will not only fail to meet its objectives but there will be a deterioration of the situation that we have already. It is a challenge the sector needs to be ready and prepared for.

For optometrists in practice, they will have a different experience based on what their local area is like, and what primary care services that area is involved in and we need NHS commissioning to support them to make it easier for them to deliver the best care for their patients.

Ongoing discussions are taking place between optometry representatives and the NHS at all levels of the NHS – local, regional and national. And concerted effort at all these levels is critical to achieve success.