NHS England's consultation on developing the long-term plan for the NHS

Our response to NHS England's long-term plan consultation, September 2018

Optometrist working on computer

The consultation

In August 2018, NHS England launched a consultation to help shape its long-term plan for the NHS, which will cover the next ten years.

The AOP’s response

Overarching questions

What are the core values that should underpin a long-term plan for the NHS?

We think the long-term plan for the NHS should be based on the aims of integrating care and improving population health.

To achieve these aims in a sustainable way, the NHS in England must make much better use of primary care. The consultation paper highlights the role of GPs and pharmacy, but optical and dental care are also vital primary health services.

Optometrists are highly trained eye health experts based in accessible, community locations. They are the front-line guardians of eye health in England and have a growing role in providing enhanced services that are traditionally performed in secondary care.

Making greater use of primary care resources, including optometrists, is a vital step in moving towards an integrated, efficient healthcare system that puts patients first, tackles health inequalities and delivers important public health interventions to an ageing population.

What examples of good services or ways of working that are taking place locally should be spread across the country?

Almost all optical practices in England deliver NHS-funded sight tests, as well as tests for private patients, and therefore detect diseases as well as correcting visual problems. In some parts of England, optometrists play a growing role in eye healthcare, relieving pressure on overstretched hospital eye services. This should happen across the country. This includes monitoring patients with glaucoma, treating minor eye problems and providing pre-operative assessments and post-operative checks for cataract patients. In the Morecambe Bay area, such services have led to tremendous improvements in capacity in local eye departments. In the first year, almost 6000 patients were seen in optical practices, which freed up hospital appointments for patients with complex conditions that can only be managed in hospitals.

Optical practices in Dudley have recently become Healthy Living Optical Practices, delivering NHS health checks and smoking and alcohol cessation services. As optical practices often see people who do not access other health services, expanding these services would provide a valuable safety net and help to address health inequalities. The lifestyle factors these services address all have an impact on eye health, so optometrists know the importance of tackling them and how to persuade patients to change their behaviour.

What do you think are the barriers to improving care and health outcomes for NHS patients?

The lack of interoperability between IT systems in different parts of the NHS is a major challenge facing the NHS.

If optical practices across England had proper digital connectivity with the rest of the NHS, they could provide better patient care more efficiently. It is unacceptable that, in 2018, optical practices often have to resort to making urgent hospital referrals for sight-threatening conditions by fax. This also prohibits the transfer of case feedback to optometrists, which is important for improving patient outcomes.

The digital transformation that the Secretary of State plans for the NHS in England must include fixing the fundamental lack of connectivity in the optical sector.

Life stage programmes - early life

How can we ensure children living with complex needs aren't disadvantaged or excluded?

According to the charity SeeAbility, adults with learning disabilities are 10 times more likely to have a serious sight problem, and this increases to 28 times for children. Unfortunately, people with learning disabilities often experience barriers in accessing sight tests. The barriers include diagnostic overshadowing, a misconception held by parents or carers that if a person cannot read, they will not be able to have a sight test and they may find an optical practice setting, or any new or unfamiliar place, off-putting and intimidating.

We said in our response to a question in the learning disability section that there should be a national pathway for people with learning disabilities in optical practices. This should be supported by a programme of sight tests and glasses dispensing in special schools, which children with the most complex needs attend.

Life stage programmes – staying healthy

What is the top prevention activity that should be prioritised for further support over the next five and ten years?

The greatest public health challenge facing society is obesity and the NHS will not be able to cope if this is not addressed. Obesity’s effect on some aspects of health, including risk of diabetes and some cancers, is well understood, but the public has little understanding of its impact on eye health. As sight is the sense people fear losing above any other, awareness raising programmes and obesity strategies should draw the link between obesity and eye problems, including the impact on development of cataracts and elevated intraocular pressures.

What are the main actions that the NHS and other bodies could take to:

a) Reduce the burden of preventable disease in England?

Demand for hospital eye care is high and growing. In 2015/16, ophthalmology was the second largest outpatient speciality in England, with over 7.5 million appointments. There were over 450,000 eye-related visits to A&E in 2016/17 and there are around 2.6 million eye-related GP appointments every year.

The RNIB says 50% of sight loss is preventable. Early detection and intervention is therefore crucial.

The leading causes of sight loss –age-related macular degeneration and glaucoma– can be asymptomatic in their early stages. People may not notice until their condition has progressed to an advanced stage, by which point it becomes harder and more expensive to treat.

General Optical Council surveys show that the public thinks sight tests are just help find out whether you need glasses or not. People do not realise that a sight test is also an important check of the health of your eyes.

The NHS must promote sight tests as a comprehensive eye health check.

b) Reduce preventable deaths?

Sight tests can pick up signs of other health problems, which could lead to complications if not treated. These include high blood pressure, high cholesterol, diabetes and brain tumours. In 2015, a pilot service was set up in the South Tees area to allow patients with symptoms of brain cancer to have checks in optical practices, with urgent onward referral directly to a local neurology department if required. The service proved to be successful and has now been rolled out across the North East.

c) Improve healthy life expectancy?

Optical practices often see people who do not access other health services, for example people who have no known health conditions, but require glasses for driving or seeing their computer. Practices can offer health advice and tests to such people.

Healthy Living Optical Practices were established in Dudley in August 2015. These practices offer smoking cessation services, alcohol screening and NHS Health Checks, such as testing glucose and cholesterol. 

Practitioners in Nottinghamshire and Derbyshire have recently become accredited to deliver the same service. Expanding these services would provide a valuable safety net.

d) Put prevention at the heart of the National Health Service? 

Properly resourced primary care is key to creating a prevention-focussed health service.  Primary care is not just GP services. Optical practices, pharmacy and dentistry can contribute to making every contact with the NHS count. Vision is an important factor in staying healthy and independent. Optometrists have a key role to play in prevention and keeping people healthy.

What should be the top priority for addressing inequalities in health over the next five and ten years? 

The whole primary care and community workforce need to be utilised to their full extent and be properly funded, particularly in deprived areas that are at most risk of health inequality. The funding of NHS sight tests – which has been frozen for 3 years – has not kept pace with the cost of delivering the test, including the use of new technology. There is a real risk that this could lead to practices in areas with a high volume of NHS work closing, which would increase health inequalities.

Are there examples of innovative/excellent practice that you think could be scaled up nationally to improve outcomes, experience or mortality? 

Optometrists working in community practices across the country are delivering services beyond sight tests, which include managing and monitoring eye diseases and treating minor problems. 

Minor Eye Conditions Services (MECS) cover symptoms like red eye, foreign bodies in the eye, flashes and floaters and discharge from the eye. Currently, over 80 CCGs have commissioned the service. An evaluation of two services in Lambeth and Lewisham published in the British Medical Journal found the service demonstrated clinical and cost effectiveness, led to a reduction in hospital attendances and had high patient satisfaction. 

Almost 6000 Minor Eye Conditions appointments were carried out across the Morecambe Bay area between September 2016 and September 2017. Before the service was introduced, these patients would have gone to hospital. The service reduced patient travel time and resulted in people being seen faster. It also freed-up hospital appointments for people with more complex conditions that can only be managed in a hospital.

NHS England needs to support and promote MECS as a national pathway, agree national tariffs, and then encourage take up of this service.

Life stage programmes – ageing well

What more could be done to encourage and enable patients with long-term health issues to play a fuller role in managing their health?

Patients should be encouraged to think of their conditions in a holistic way.

One success story in eye care over recent years is the uptake of annual diabetic eye screening, which is at 80% - much higher than any of the other screening programmes. This is why diabetic eye disease is no longer the leading cause of sight loss in the working age population. While this is something to be celebrated, if patients with type 2 diabetes were encouraged to manage their condition and where possible reverse it, there would be less need for eye screening.

Glaucoma is the second biggest cause of sight loss in the UK and can be symptomless in its early stages. Regular sight tests are therefore crucial in detecting the condition. If glaucoma is detected in its early stages, treatment, in the form of eye drops, can prevent progression of sight loss. For patients whose condition can be managed by eye drops, these need to be taken regularly and in the correct way. Optometrists are well-placed to support patients with this chronic condition, advising them on how to use drops and checking they are complying.

How can we build proactive, multi-disciplinary teams to support people with complex needs to keep well and to prevent progression from moderate to severe frailty for older people?

Falls are a major challenge for the frail and elderly population. People aged 65 and older have the highest risk of falling, with 30% of people older than 65 and 50% of people older than 80 falling at least once a year. Preventing falls in this group depends on addressing a number of factors, including balance, gait, hearing and vision.

Vision is fundamental to coordinating our movement – balance and postural stability are directly affected by vision.

Optometrists are therefore an important part of the multidisciplinary team, and vision should be a consideration in all aspects of a patient pathway through falls services - including prevention and rehabilitation programmes.

People who are unable to leave their home due to physical disabilities or mental illness are entitled to have NHS-funded sight tests at home. More needs to be done to raise awareness of this service, particularly among the older population.

What are the main challenges to improving post-diagnostic support for people living with dementia and their carers, and what do you think the NHS can do to overcome them?

A diagnosis of dementia can be difficult to come to terms with. Carers can overlook patients’ other health needs and patients may no longer notice, or be able to describe, their situation. All too often it is assumed that someone with dementia will not benefit from having a sight test and vision correction simply because they have cognitive impairment and may not work, drive or read. However, good eye health and vision can play an important role in supporting the well-being of a person living with dementia. While they may not drive, read or work, good vision is still essential for other near tasks, including simply eating, getting dressed or looking at photographs of loved ones. Good vision can greatly increase a person’s sense of independence, allowing them to continue to participate in daily tasks and activities and maintain a good quality of life.

What is your top priority to enhance post-diagnostic support for people living with dementia and their carers?

Our top priority would be to ensure that once a person is diagnosed with dementia, their eye care needs are addressed as part of the planning of their overall care package. Again, we would like to highlight that people who are unable to leave their home unaccompanied are eligible to have an NHS-funded sight test at home (or a care home), and this should be highlighted to people with dementia, their carers and other people involved with their on-going care.

Clinical Priorities – learning disability and Autism

How can we best improve the experiences that people with a learning disability, autism or both have with the NHS, ensuring that they are able to access the full range of services they need?

Adults with learning disabilities are 10 times more likely to have a serious sight problem, and this increases to 28 times for children. Unfortunately, people with learning disabilities often experience barriers in accessing sight tests and appropriate eye-care.

Barriers include: 

  • Diagnostic overshadowing
  • Uncertainty about costs and eligibility for GOS (NHS) sight tests and complexity of current eligibility requirements
  • Misconceptions from families, carers, and staff that individuals must be able to read and communicate verbally to undertake a sight test
  • The fear of unfamiliar environments
  • The perceived challenges of access to reasonably adjusted optometry services in community settings
  • A lack of training and information on recognising eye and vision problems for care staff, families and professionals working with people with learning disabilities and autism. 

Possible solutions: 

  • A national learning disabilities sight-test pathway adequately funded to allow reasonable adjustments including extended examination times or repeated appointments
  • Eligibility for all people with learning disabilities or autism to NHS funded sight-tests 
  • Embed eye-care and vision training in all professional training schemes and improve information for care staff
  • Encourage commissioners to demand that periodic sight testing is part of all care plans
  • Improve flagging of reasonable adjustments required in patient referrals and secondary care notes.

Enablers – workforce

What is the size and shape of the workforce that we need over the next ten years to help deliver the improvements in services that we would like to see?

There are around 15,000 optometrists in the UK, the majority of whom are not NHS employees, but work in community optical practices (“Opticians”) carrying out sight tests and prescribing glasses etc. Around a thousand optometrists are employed by the NHS in Hospital Eye Services.  

There has been no formal analysis of the future workforce requirements in optics.  Increasing population need implies that we will need more optometrists, although this requirement could eventually be offset by technological developments.

Currently there are recruitment issues in both hospital and community optometry. 25% of the employers responding to the AOP’s 2018 workforce survey had a vacancy - managed by employing locums or seeing fewer patients. 

It is important that optical education provides enough well-trained entrants to the workforce. In future optometrists will be needed to carry out the more complex tasks of diagnosis, prescribing, treatment and advice, as technology reduces the time needed for simpler tasks. Health Education England should be encouraged, nationally and regionally, to provide appropriate educational support for enhanced community optical service delivery models which can reduce pressures on hospital eye services. 

How should we support staff to deliver the changes and ensure the NHS can attract and retain the staff we need? 

NHS England should consider how to best meet the needs of a changing workforce, where employees work increasingly flexibly.  

Attracting, retaining and supporting staff will more than ever depend on appealing to people’s values and recognising their wider commitments and responsibilities to family and community, as well as their desire for flexibility in their working hours and patterns.

A recent AOP survey of our members identified their career aspirations and also the non-work factors that motivate their career decisions. Respondents described values and location as important to them and quoted family, social networks and caring responsibilities as factors that attract them to stay with an employer or to move jobs. 

This survey confirmed a trend over several years of a growth in the proportion of optometrists choosing to work as locums. Around a quarter of respondents worked as locums. This is not because they cannot find permanent positions. It is a deliberate choice which is mainly due to the flexibility it offers.

NHS employers will increasingly need to recognise and cater to the aspirations of employees for flexibility and a workplace that supports people to balance work with family and community.

What more could the NHS do to boost staff health and well-being and demonstrate how employers can help create a healthier country?

The AOP surveyed its members about their health and well-being in 2017. We found the top sources of stress in optics are deadlines; feeling responsibility without matching respect; the need to prove oneself; lack of control over one’s day/tasks; insufficient time with patients; poor work/life balance; and not feeling supported by one’s manager or colleagues. 58% of respondents said they had changed employer one or more times due to stress they had been experiencing.  This set of factors may play a greater part in the lives of optometrists, most of which work in a commercial environment where the sale of glasses and contact lenses generally subsidises the clinical work. However, many of these experiences are similar to many health workers in other busy target-driven NHS settings.  Employers need to pay attention to these factors, many of which are simply about the organisation of the working day and the behaviour of and relationships with colleagues.

Enablers – primary care

How can the NHS help and support patients to stay healthy and manage their own minor, short-term illnesses and long-term health conditions? 

Patient education is key to helping people manage their condition and take pressure off the health service. This was supported in a recent Health Foundation study which showed 690,000 A&E appointments could be saved if people were supported to better manage their own conditions. 

Optometrists working in the community are well placed to support people with eye conditions. Long-term conditions like glaucoma and age-related macular degeneration can have a dramatic impact on a person’s day-to-day life. Optometrists have the skills and knowledge to manage these patients in the community and explain their condition, and how to mitigate against further progression of the disease, by, for example, using eye drops correctly. For people with sight loss, they can also help by advising on low vision aids – which enable people with low vision to do things like watch television and read.

It is also important to instill good health habits, including regular sight tests, from a young age. This is not only important because of the growing prevalence of myopia in children and the need to treat conditions like amblyopia (lazy eye) before it’s too late, but also so children grow up knowing the importance of maintaining good eye health. 

How could services like general practice and pharmacy, work with other services like hospital services to better identify and meet the urgent and long-term needs of patients? 

Optical practices should be commissioned to deliver extended eye care services, working in conjunction with hospital eye departments. This would help ensure patients are seen in the right place, and at the right time. The Local Optical Committee Support Unit has developed pathways for the commissioning of community eye services, which are operating successfully in many parts of England. 

In Gloucestershire, several services were commissioned in 2016, including a Minor Eye Conditions Service, a glaucoma referral refinement service to decrease false-positive referrals to hospital and a children’s vision screening pathway. They have also commissioned a post-operative check pathway from optical practices, which, in its first year, saw 1000 patients and allowed nurse practitioners to be re-deployed in the emergency eye service. 

Lack of IT connectivity between optical practices and other parts of the NHS is a barrier to effective joint working. This prohibits the transfer of feedback between ophthalmologists and optometrists, which is important for improving patient outcomes. 

How could prevention and pro-active strategies of population health management be built more strongly into primary care?

Primary care is perfectly placed to deliver preventative health care. As mentioned in response to an earlier question the Healthy Living Optical Practice service in Dudley has been successful in delivering health messages and interventions, including to people who do not visit other parts of health care, such as GPs and pharmacies. 

It is also important that local and strategic plans include eye care. When STPs were launched, only a handful of their plans included eye care, and those that did often only included a passing reference. Public Health England’s recent health profile of England highlighted that although sight loss is increasing and has a debilitating effect on a person’s day-to-day life, it does not receive the attention it deserves. NHS England now has the opportunity to address this and ensure eye health is given the right priority.

Enablers – digital innovatioN and technology 

How can digital technology help the NHS to: 

a) Improve patient care and experience? 

There are around 7.5 million outpatient appointments in ophthalmology. This represents the second largest outpatient volume of the main attendance categories. Patients often face long waits for secondary care ophthalmology appointments. Many of these appointments could be delivered in primary care optometry if true NHS IT connectivity was implemented. This would allow real time collaboration between professionals and reduce the volume of secondary care appointments, freeing consultants to better deal with the increased burden of an ageing population. This would also reduce stress and inconvenience to patients and allow care to be delivered closer to home. New technology such as Optical coherence tomography (OCT) if suitably connected would allow for either AI second opinion or consultant second opinion before onward referral. Many optical practices are open for extended hours and across weekends. They are also located in easily accessible locations providing significant patient choice. This provides less disruption, necessitates less time off work, which is particularly important for those who either require care, or provide care to others. 

b) Enable people and patients to manage their own health and care?

Currently many of the primary and secondary care systems exist in isolation. This prevents real time sharing of data and information and leads to unnecessary duplication and delays in care.
9 out of 10 households now have internet access. By providing online appointment and record access alongside the ability to arrange, manage, and change appointments, there is a potential to reduce the administrative burden on the healthcare system. This is only possible by increasing the connectivity of all parts of the healthcare system. 

c) Improve the efficiency of delivering care?

By delegating tasks and episodes of care to optometrists, ophthalmologists will have greater time to deal with the more complex multifactorial patients who are increasing in prevalence due to the ageing population. This will decrease the time to first appointment and reduce the risk of avoidable blindness. This reduction will also allow for more timely follow ups with the same effect. 

From the perspective of the patient, as optical practices are located within communities, there is the potential to reduce the transport costs associated with attending hospital appointments. It is a commonly reported fact that patients with long term conditions, such as glaucoma, have to attend for multiple appointments due to hospital scheduling. In many instances these could be combined into a single appointment, delivered in optical practices and with a significant reduction in cost to the NHS. 

What can the health and care system usefully learn from other industries who use digital technology well? 

Changes in society, such as the rise of social networks and peer to peer services such as Airbnb show that what people value isn’t simply cost, it is convenience. More people have working patterns that no longer fit traditional working arrangements. This is coupled with changes in childcare or the need to care for other relations. Patients need a healthcare system that reflects this, with appointments and consultations being delivered when patients want, rather than when it suits the healthcare system. The healthcare system needs to move from traditional hospital-led delivery to more local, flexible services. In eyecare this means making greater use of optical practices in the community.  As elsewhere, it is vital that the NHS does as much as possible to implement the digital and technological innovations that have the most potential to change the way that care is provided to patients to improve outcomes and experience. 

It is important we plan carefully so that the public and the NHS understand how to get the best from these changes, better supporting our workforce in their role but also the public in preventing illness and accessing their care.

How do we encourage people to use digital tools and services? (What are the issues and considerations that people may have)?

There are still concerns over data security and access in certain subgroups of the population. These are often the hardest to reach groups. Also, patients find it very frustrating that they have to repeat history and symptoms questions they have already provided to other healthcare practitioners and worry that they or their relatives may forget to relay pertinent information. To help to eliminate these concerns, patients need assurance that the information that the provide will be safely and securely stored and transmitted and accessible by all relevant healthcare practitioners. For this to happen there is a need for robust data connections between primary care optical practices and the rest of the healthcare system. 

How do we ensure we don’t widen inequalities through digital services and technology?

Households with one adult over the age of 65, despite being the group with the largest growth in internet usage, also represent the group with the lowest percentage of internet access at 59%. One of the greatest challenges to the NHS at present is the ageing population. This is often attributed to people living longer, with more complex health needs and increasing co-morbidity. To avoid widening health inequalities we must ensure that in the drive for greater efficiency we do not leave behind this most vulnerable group. The only way to ensure this is a steady transition of technology and ensuring there are failsafe traditional methods for those that need them, whilst encouraging the majority of the population to move the more efficient modern system.