The expanding role of optometrists

Optometrist with patient trying on glasses
Photo taken before COVID-19

Optometrists are the healthcare specialists who carry out sight tests, which are also known as eye examinations. This role is set out in the Opticians Act of 19891. Most optometrists work in the thousands of High Street optical practices that are commonly known as opticians, although some work in hospitals, and others provide services in care homes and other settings.

Optometrists prescribe spectacles and contact lenses to the estimated three-quarters of the population who need vision correction. This means that they contribute hugely to the well-being and economic productivity of our population.

They also identify and treat disease. Optometrists are often the first people to identify common sight-threatening conditions like cataract, glaucoma and age-related macular degeneration. They can then refer patients to hospital eye services for diagnosis and treatment.

Optometrists can also identify other diseases, including diabetes and cancer, and by doing so can save lives.

Beyond the role prescribed in the Act, optometrists can:

  • Provide treatment for patients with minor eye conditions who otherwise present at their GP or emergency departments
  • Reduce the number of unnecessary referrals to ophthalmology outpatient departments
  • Monitor and follow-up appropriate patients in the community, instead of in hospital, therefore freeing up hospital appointment slots for first-time attendees and those who need the care of an ophthalmologist

There is also a growing number of independent prescribing (IP) optometrists2 who are qualified to provide additional diagnosis and treatment.

But neither IP nor regular optometrists can work to their fullest capacity unless they are funded to do so. The Welsh and Scottish governments have both created expanded systems of NHS eye care delivered in optical practices so that optometrists can use their skills to treat people in the community. There is work going forward in both countries to improve these schemes further.

In Northern Ireland there has been regional progress on a number of fronts. These include glaucoma referral refinement, the majority of practices now managing minor eye conditions; and post-operative cataract care being carried out in the community from September 2021. Waiting lists for cataract surgery are very long in Northern Ireland (approximately two years) but having a review take place in the community will allow hospitals to concentrate on carrying out the surgery.

The English experience is even more fragmented. England lags behind the other UK nations because these extended primary care services have to be commissioned locally and there has been little central direction until now. Commissioning is starting to happen on a wider scale as Clinical Commissioning Groups (CCGs) merge and some commissioning takes place at a Sustainability and transformation partnerships (STTP) or integrated care system (ICS) level. COVID-19 also led to more local commissioning of urgent eye care services in the community. New NHS Planning Guidance will see this change, but until that starts to have an effect there remains a lack of consistency between areas which results in amounts to a postcode lottery for patients.

Giving primary care optometrists a greater role in eye healthcare is beneficial both for patients and for the NHS:

  • Patients who can be treated in the community prefer it, because they can access high quality care in a convenient location, usually with less waiting time
  • It frees up the time of hospital eye departments to concentrate on those patients who need to be seen by an ophthalmologist 
  • More community treatment is good for the NHS because it means every patient is treated in the most appropriate and cost-effective setting

The potential is great. The chart below was produced before the pandemic to demonstrate the effect on hospital demand of extending the coverage of schemes that already exist in parts of England. It was put together at an early stage of the work that is now covered by the national eye care recovery and transformation programme. It draws on prior work for the ophthalmology specialty report for the Getting it Right First Time programme3.
Clinically led re-design of ophthalmology pathways diagram

Optometrists also work within hospitals, running clinics that were previously run by doctors, thus releasing ophthalmologists to carry out surgery and more specialised roles. This development was accelerated by COVID-19, as ophthalmologists were called away to COVID-19 wards and hospital optometrists stepped up to fill the gaps. More and more ophthalmologists are seeing the potential role of community optometrists in taking these developments further. The table below shows the estimated reduction in the need for hospital appointments in three areas of care as a result of developing the community schemes we are recommending.

Evidence based for appts done differently or avoided diagram

Community optometrists could also play a greater role in supporting the health of the nation more generally. An example is how many optometrists became vaccinators during the pandemic. They could play a similar role in the annual flu vaccination programme.

In fact, optometrists are already giving health advice all the time. The links between lifestyle and eye disease are not widely known in the community and optometrists are ideally placed to explain the links between eye disease and smoking, diet, and obesity to their patients and many already routinely do so. This role as part of the wider health care community is not currently recognised.

Many practices have already chosen to add other healthcare services to their offer, audiology being the most common.

Beyond that, optical practices in some parts of the country are playing a greater role in tackling public health challenges, by delivering healthy living services. The healthy living optical practice model3 originated in Dudley and is based on the healthy living pharmacy model. The concept is that when a person visits their optical practice for eye care reasons, they will also be able to access smoking cessation services, alcohol screening, NHS Health Checks including glucose testing and cholesterol, and weight management.

Although the appetite for diversification into other areas of healthcare is not shared by all optical practice owners and not all will want to develop formal involvement in public health initiatives, there is a clear opportunity here for those that do.