Our response to the Department of Health and Social Care major conditions strategy call for evidence

This is our response to the Government consultation on the major conditions strategy call for evidence. The consultation ran from 17 May to 27 June 2023.

The consultation sought views and ideas on how to prevent, diagnose, treat and manage the six major groups of health conditions that most affect the population in England. These are:

• Cancers
• Cardiovascular disease, including stroke and diabetes
• Chronic respiratory diseases
• Dementia
• Mental ill health
• Musculoskeletal disorders

The views and ideas gathered will inform the priorities and actions in the major conditions strategy due later on this year.

It was important for the AOP to response given the role optometry plays in the early diagnosis of a range of wider health conditions that can be identified though sight testing and eye health ‘screening’ such as diabetes, dementia and some cancers and the future opportunities optometrists can play as high street primary care providers in the identification of other major health conditions such as cardiovascular disease.

Our response

Cardiovascular disease

Cardiovascular disease (CVD) is a general term for conditions affecting the heart or blood vessels. It is one of the main causes of death and disability in the UK, and includes coronary heart disease, strokes, peripheral arterial disease, and aortic disease. Atrial fibrillation (an irregular, and sometimes fast heartbeat), high blood pressure, and high cholesterol are all risk factors for CVD. Evidence suggests taking action on these three risk factors will significantly reduce the number of strokes, heart attacks, and other types of CVD.

How can we successfully identify, engage and treat groups at high risk of developing CVD through delivery of services that target clinical risk factors (atrial fibrillation, high blood pressure and high cholesterol)?

Optometrists are part of the NHS primary care workforce. They provide skilled clinical care such as sight tests (determining the need for spectacles, in conjunction with a mandated eye health examination). They also conduct targeted eye health examinations in response to patient concerns such as the Community Urgent Eyecare Service, (CUES). The sight test is the main point of identification of eye health disease in the UK. During the sight test, optometrists often identify underlying general health conditions, such as signs of diabetes, hypertension and raised cholesterol. They also identify signs of primary and secondary eye and brain tumours.

Optometry appointments also present an additional point of engagement with patients, who may not routinely visit their GP or other health practitioners. This presents an opportunity to check for signs of raised blood pressure, diabetes and cholesterol. As well as interventions around healthy eating and alcohol consumption.

Given our aging population and the increasing prevalence of long term health conditions that are associated with lifestyle, the importance of tackling health inequalities and therefore the role of primary care optometry as the first point of contact in the whole eye care pathway is vital for both early detection and prevention. Optometrists already prevent many unnecessary escalations into secondary care, but could do much more if commissioned to do so. They could also provide follow-up after the acute phase of care. The presence of an optometric practice on pretty much every High Street means that they are convenient and accessible for patients.

The Clare Fuller Stocktake highlighted the need for greater parity across primary care in order better to address public health needs, support early detection, and early intervention and prevention. In our response to the Hewitt review on ICS accountability we highlighted the key role primary care optometry could play in working with ICSs to deliver against the 2023/24 NHS Operating Framework and planning guidance and the 2023/24 national NHS objectives of - increasing to 60% the proportion of patients aged between 25 and 84 years with a CVD risk score greater than 20 percent on lipid lowering therapies to 60%. There is significant  potential for optometrists to detect CVD risk as an indirect outcome of the detection of diabetes, hypertension and high cholesterol.

However, there are opportunities for optometrists both in community and hospital settings to carry out finger prick tests for heart disease or cardiovascular risk within their clinical setting, or through more direct working/referral with pharmacy.

Tackling the risk factors for ill health

The condition groups we are focusing on are often driven by preventable risk factors, with nearly half (42%) of ill health and early death being due to them. This includes tobacco, alcohol, physical activity, and diet-related risk factors. Action on preventable risk factors is also central to our work on tackling health disparities, since people living in more deprived areas are more likely to partake in these behaviours. Do you have any suggestions on how we can support people to tackle these risk factors?

How can we support people to tackle these risk factors?

You might consider suggestions on how we could:

• Make changes at a local level to improve the food offer and support people to achieve or maintain a healthy weight and eat a healthy diet
• Identify and support inactive people to be more physically active
• Support people to quit smoking, including through increasing referrals to stop smoking support and uptake of tobacco dependency treatment
• Support people who want to drink less alcohol to do so

Suggestions for tackling the risk factors for ill health

Optometrists already do a lot to tackle the early risk factors for ill health, through the detection of lifestyle related conditions such as high cholesterol, hypertension, diabetes etc. Optometrists will also refer and or signpost patients to other parts of primary care or secondary care for further clinical care and onward linking to other parts of primary care or third sector organisations.

At the AOP, we are working with organisations such as the NHS confederation to embed the much-needed parity of esteem in primary care alongside communicating the importance of good mental and physical health and wellbeing across the whole life course, through engagement with eye care services.

The new health commissioning and delivery landscape in primary care means high street health services have the potential to embed themselves into their communities as a source of health and wellbeing and have the potential to facilitate a move towards preventative and community care.

Moreover, high street health offers the potential to keep patients away from overburdened GP practices and emergency departments. In primary care optometry we have over 6000 practices in England, highly accessible with many open six or even seven days per week.

Supporting those with conditions

This part of the survey seeks to understand how we can improve outcomes for people with any of the major conditions, or a combination of them, across their life course. For these questions, we ask for you to consider the following in your responses:

• How we can improve outcomes for people across the life course, from pre-conception, early years, childhood and young adulthood, into adulthood and older age
• How we can target population groups most in need - including addressing disparities in health outcomes and experiences by gender, ethnicity and geography
• What could be adopted and scaled quickly (that is, in the next 1 to 2 years) with impact
• What we can learn from local, national and international examples of good practice, and what wider factors are either enabling them to be a success or are blocking them from being even more successful
• If you’ve tried a particular approach with success, please indicate the cost and be as specific as possible about how the approach was implemented

You have the option of suggesting ideas for:

• Multiple conditions
• CVD
• CRDs
• MSK conditions
• Dementia

Supporting local areas to diagnose more people at an earlier stage

Do you have any suggestions on how we can better support local areas to diagnose more people at an earlier stage? (You might consider suggestions to increase capacity available for diagnostic testing or identify people who need a diagnosis sooner).

Yes, as referenced previously, Optometry (primary care, domiciliary or hospital optometry) presents an additional point of engagement with patients, who may not routinely visit their GP or other health practitioners. This gives an opportunity to check for signs of raised blood pressure, diabetes and cholesterol, as well as offering interventions around healthy eating, alcohol consumption and smoking.

The Healthy Living Optical Practices schemes in Nottinghamshire, Dudley and Derbyshire offers a range of additional healthcare to patients such as a range of NHS health checks and screening services. The scheme provides free health champion and leadership training to support the programme, including an accredited Royal Society of Public Health certificate, enabling practices to become a healthy living accredited optical practice. The programme has demonstrated great results, for example in the pilot of the Dudley scheme they:

• Had over 12,000 conversations about alcohol which highlighted 14% of individuals screened were drinking at harmful levels. These individuals received brief advice and one individual was referred into specialist support
• Recruited 36 individuals into a Stop Smoking Service and achieved a 42% quit rate
• Performed 316 NHS Health Checks which identified 237 people as being overweight or obese, 51 people with high blood pressure and 88 people with raised glucose levels
• Had conversations with the public about a whole range of lifestyle factors; 98% of people questioned said they believed optical practices were suited to deliver public health services and messages
• Influenced many lifestyle changes with their patients. Quote from Health Champion ‘we have advised on diet and increasing activity levels, in one case the patient bought a push bike!’

High Street eye care, led by clinically qualified optometrists, is already supporting early detection and prevention across the whole range of multiple conditions highlighted in this draft strategy. However, through advancing current integrated and collaborative approaches for working across the health and care system, we can do more. There are significant untapped opportunities in specific screening for CVD in Optometry settings, as opposed to identifying CVD risk.

How can we better support and provide treatment for people after a diagnosis?

You might consider suggestions that help people to manage and live well with their conditions, with support from both medical and non-medical settings.

The RNIB estimate that every day, 250 people start to lose their sight (Deloitte Access Economics, 2017). People with sight loss are more likely to suffer depression with more than four in 10 people attending low vision clinics suffering from symptoms of clinical depression (DEPVIT, 2016). Nearly a quarter of blind and partially sighted people (23 per cent) leave the eye clinic not knowing, or unsure of, the name or nature of their eye condition (Douglas, Corcoran and Pavey, 2006).

In secondary care, the eye care liaison officer (ECLO) is the most effective way of supporting patients and helping them to understand the impact of their diagnosis, providing them with emotional and practical support. ECLOs work closely with clinical teams but have the time to dedicate to patients following consultation. This is badly needed because increasing demand, long standing issues in Ophthalmology and shortages in the ophthalmic workforce mean that patients do not necessarily get the time they need to learn about and come to terms with their condition alongside a professional. ECLOs are endorsed by NICE, DHSC, the Royal College of Ophthalmologists and UK Ophthalmology Alliance.

Outside of hospital setting the RNIB is leading a project to identify the eye care support pathway that will enable people to understand and come to terms with their conditions. The work originated from focus group work with patients designed to gather what information and emotional and practical support they need, not just after diagnosis, but also during that potentially worrying time between referral and diagnosis. The AOP is a partner in the ongoing work on this.

The work has identified patients' needs beyond clinical care, and will result in an eye care support pathway that will be widely supported across optics, ophthalmology, the third sector, and social care. The intention is to upskill practice staff in high street optometry practices to be able to contribute to this important activity.

How can we better enable health and social care teams to deliver person-centred and joined-up services?

You might consider suggestions to improve the skill mix and training of the health and social care workforce.

The recent Royal College of Ophthalmologists workforce census found that the vast majority of NHS ophthalmology services are facing significant capacity pressures, with over three quarters (76%) not having enough consultants to meet current patient demand and over half (52%) finding it more difficult to recruit consultants over the last 12 months. These shortages are creating delays for patients across the UK. In January 2023, there were over 632,000 patients on ophthalmology waiting lists in England alone – 24,000 of whom were waiting over a year. 63% of eye units estimate it will take at least a year to clear their outpatient backlogs.

It is further predicted workforce shortages in NHS eyecare services are set to worsen, with a quarter (26%) of consultants in the UK planning to leave the workforce over the next five years (the majority retiring), while 28% plan to work in independent sector providers – up from just 16% of the workforce currently.

Meanwhile in optometry our clinical workforce is buoyant and well placed to take on more work traditionally delivered in secondary care. The ‘Optometry First’ project was designed and developed as part of a wider eyecare delivery framework. Its purpose is to reduce pressure on secondary care services and provide more responsive care closer to home through community based optometry practices.

Whilst there is always some geographical disparity this is less prevalent in optometry. This sustainable position within the optometric workforce means the design and delivery of holistic care for the types of conditions identified in this draft strategy can be deployed in a consistent and clinically safe way, whilst still acknowledging local disparities and health needs.

How can we make better use of research, data and digital technologies to improve outcomes for people with, or at risk of developing, the major conditions?

The lack of widespread IT connectivity in England is one of the most significant issues in eye care. It impacts negatively on the ability of optometrists effectively to treat patients as there are gaps in knowledge of the patient’s previous referral and treatment journey. The inability to e-refer into and out of secondary care is a huge issue for the effective delivery of primary eye care services through an integrated/shared care model. Lack of IT connectivity can lead to unnecessary referrals (often because optometrist don’t have background or patient history) and contribute to secondary care backlog and blockages. This is frustrating given Optometrists are clinically trained and able to see patients for post operative appointments following cataract surgery.

Widespread lack of feedback to the referring optometrist means that they cannot improve their referrals, do not know what has happened for their patients, and cannot identify any clinical risk associated with delayed referral follow-up.

Secondly the current process for the collection and sharing of data across the system is complicated. There are no measures that set out what data is collected, reported and what data is omitted. Given the wealth of data collected in healthcare there seems so be a lack of consistency and understanding of the type of data that is collected, what is useful data or not and why and how it is used in terms of performance-monitoring and academic research.

The use of AI and other digital technologies are also improving services and outcomes for patients. In eyecare, for example the use of optical coherence tomography (OCT scans) has increased dramatically, eg at Moorfields Eye Hospital NHS Foundation Trust numbers have increased 14-fold since 2008, with the Trust now holding a repository of 20 million ophthalmic images. Crucially these images and the associated ‘raw’ data can be used in research for wider conditions such as those listed above.

Another innovative piece of research is exploring how data captured from images taken in optometric practices can be used to discover new warning signs of Age-related Macular Degeneration (AMD) which are undetectable by a human observer. (AMD is now the leading cause of sight loss among older people). Using artificial intelligence (AI) algorithms to analyse the data, scientists aim to understand whether certain people may be at a higher risk of AMD manifesting or progressing. The data will help design new treatments to slow progression, or halt it altogether.

Mental Health

The mental health call for evidence published in 2022 provided useful insights that will shape the development of the major conditions strategy. However, if you wish to, we wanted to provide an opportunity to provide any further insights in this call for evidence.

How can we better support those with mental ill health?

Research has found that visual impairment affects learning and development and mental health from a young age, with one in four adults with vision impairment going on to experience anxiety and depression.

There is growing support for the introduction of mental health ‘screening’ as part of standard optometric care where the clinicians feel an assessment is required. Recent proposals from the Welsh Government on Ophthalmic reforms set out the intention to include depression screening into the suite of health and wellbeing advice in practice.

In their evidence to Scottish Government on Alternative pathways to primary care (2022), Optometry Scotland cited evidence that older people with eye diseases are three times more likely to limit their activities due to fear of falling, compared with those who have good vision. This highlights the broader preventative benefits of treating these conditions. This has a direct correlation with mental health such as anxiety and depression. Optometry Scotland stated: "The collateral benefits of addressing visual impairment on fall prevention, dementia, and other mental illnesses are already documented".