The problem with NHS funding

A woman having a sight test
Photo taken before COVID-19

As we have described, the Scottish and Welsh governments have both made deliberate and successful efforts to integrate primary eye care providers into NHS provision. This has resulted in more care taking place in the community, and fewer unnecessary hospital attendances.

It has taken some investment in order to reap these rewards.

In Wales, this has been achieved by supplementing the NHS sight test through EHEW, while Scotland has replaced the sight test with a better-funded and more comprehensive eye examination. Both the Scottish and Welsh governments are working closely with optometrists to build on these successes.

Despite some statements of intent and positive developments, we haven’t seen the same progress in England. A significant barrier to achieving similar changes in England and Northern Ireland is the continuation of the way that eye care is funded there, and the significant under-funding of the NHS sight test.

Optical practices in England now receive £21.79 for each NHS sight test they carry out. (This is more than 13 million sight tests in England26, 795,000 in Wales27  and 470,500 in Northern Ireland28). It is widely accepted that this figure does not cover the cost of providing the sight test. The GOS sight test fee in England was frozen for five years before a 1.9% increase in 2021, and even so it remains far below the cost of delivering the sight test. The fee is 25% lower in real terms than it was in 1948, while the test done in 2021 is far more sophisticated (and more costly to deliver) than the test delivered in 1948.

Primary care optometry forms a network of easily-accessible healthcare locations - the commonly-recognised opticians of the High Street. Because the GOS sight test fee does not cover the cost of providing the sight test, the viability of this network is dependent on income from sales of spectacles and contact lenses. Thus NHS services are effectively subsidised by people who do not qualify for NHS sight tests, and particularly by people who wear spectacles and contact lenses and pay for them privately.

Although many people, particularly spectacle wearers, might regard this as obviously unfair, it has remained sustainable due to the healthy competition and good customer service in the optical sector. People have been content to take advantage of “free” private sight tests and two-for-one offers and purchase their eyewear from the practice that prescribes it.

This will not continue.

More and more people are taking their prescription from the practice where they receive it and getting it made up elsewhere, often online. Mintel’s 2019 Optical Goods Retailing report29 identifies that 10% of purchasers buy online, particularly contact lenses. These purchasers are younger and wealthier than the average, which indicates that they are crucial to the future of the market. The Mintel 2020 Optical Goods Retailing report says:

“Today’s consumers expect to shop online for a wide range of goods and services, and this indicates that there will be growing enthusiasm for buying optical goods online.

However, people value the role of a specialist optician – 83% of adults feel that it is important to have prescription glasses fitted professionally at an optician and 67% think it is important to buy contact lenses from an optician that does check-ups. These factors continue to encourage shoppers to visit an optician when buying glasses or contact lenses.

But 44% recognise that shopping online for spectacles or contact lenses can save a lot of money… Plus, the realisation that 26% of all, rising to 47% of 16-34s, would test their own eyes with an app indicates an appetite for avoiding an opticians visit.”30

The General Optical Council (GOC) carries out occasional research on the behaviour of contact lens wearers and optical consumers more generally. 2016 research found that 26% of contact lenses wearers bought their contact lenses online “all the time”, with a further 58% buying them online “regularly”31. The GOC’s 2021 research asked specific questions about the impact on COVID-19 on patients’ behaviour, including delaying their sight tests and any associated spending on glasses or contact lenses. The report notes that:

“As well as delayed expenditure there is some evidence of channel shift in purchasing, with 11% indicating that during the pandemic the way in which they buy glasses and contact lenses has changed Eg. making purchases online. Changes to purchasing patterns were most common among those aged under 44 (16-24: 14%, 25-34: 16%, 35-44: 14%).”32

While most people, particularly older people, appreciate the personal one to one relationship with the optometrist in the consulting room, many will increasingly feel comfortable taking the retail element of the transaction elsewhere. COVID-19 has accelerated the trend of online buying in the UK. Mintel’s April 2021 Retail and e-commerce report33 says that online shopping increased by 46.9% in 2020, and although many consumers report that they are looking forward to going back to into physical shops, 27% are expecting to buy more online post-pandemic than they did before. There has also been a move towards shopping more locally, which has affected footfall in shopping centres.

The common understanding of the High Street optician is as a retail premises, but the NHS needs this vital network of physical optometric practices. But, already affected by the decline of the High Street, it is vulnerable to these changes in consumer habits. When practices close, people will need to travel further or wait longer to get an NHS sight test.

Meanwhile the current funding model works as a disincentive for optical businesses to become more involved in NHS work. Many want to do so and are prepared to have reduced earnings as a consequence, but loss-making NHS activity will suffer when business viability depends on selling spectacles. More and more practices are considering reducing the times they offer NHS sight tests and some are considering withdrawal from GOS completely.

26General Ophthalmic Services activity statistics - England, year ending 31 March 2019
27Sight Tests by Local Health Board – Wales 2018-19
28Family Practitioner Services Statistics for Northern Ireland 2018/19
29Mintel, Optical Goods Retailing, UK, February 2020, p 21
31General Optical Council, Contact Lens Survey, February 2016 Page 23