Primary care eye health services

The NHS should use optical practices in England to provide more eye healthcare

Optical practices in England can and should provide more eye health care services on behalf of the NHS. This will help patients, relieve pressure on hospitals and GPs, and save the NHS money.

What’s happening

Most eye health problems are treated in hospitals. Demand for hospital eye care in the UK is high and growing – Around 7.5 million outpatient appointments in England are for eye care, which, at 8%, is the largest outpatient specialty¹. Analysis by NHSE’s National Eye Care Recovery and Transformation Programme (NECRTP) shows that, without activity rising well above business as usual, it will take more than five years to clear the backlog.

Attendances grew by 16% between 2011/12 and 2021/22². There are around half a million visits to A&E in England per year³ and there are an estimated 2.6 million eye-related GP appointments every year.

Hospital eye clinics are already working at full capacity. The British Ophthalmological Surveillance Unit has found that at least 20 people a month⁴ are losing vision unnecessarily because of delayed follow-ups in hospital – a tragic and unacceptable situation. And as the UK’s population ages, with the number of people aged over 65 projected to rise by over 40% in the next two decades, more people will need treatment for serious eye diseases such as cataracts, glaucoma and age-related macular degeneration (AMD). The Royal College of Ophthalmologists estimates that glaucoma cases will increase by 44% over the next 20 years, and AMD cases by 60%⁵. In the absence of extra resources, hospitals will be unable to cope.

But help is at hand. Optometrists – who work in optical practices located in every community in the UK:

Are highly trained and regulated eye care providers
Are equipped with modern examination and diagnostic aids
Can treat and manage a wide range of eye conditions and diseases

Nearly all UK optometrists already provide NHS services such as sight tests, as well as offering other eye healthcare services.

Giving optometrists a greater role in eye healthcare is good news for patients, who can access the care they need quickly and conveniently in a local optical practice. Patients welcome the opportunity to receive prompt, high-quality care in these local settings rather than having to wait for an appointment at a busy and often distant hospital.

During the COVID-19 pandemic COVID-19 Urgent Eyecare Service (CUES) was set up to provide urgent and emergency services in primary care settings. This provided a successful model to deliver emergency care where needed.

Moving more healthcare into optical practices is also good for hospitals and the NHS. It means fewer and more accurate patient referrals into secondary care and reduces the pressure on hospital eye clinics and A&E departments, enabling them to focus on patients with complex and urgent problems.

What needs to change

Optometrists can only fulfil their potential to provide more eye healthcare, and relieve pressure on the rest of the NHS, if they are given the opportunity. The NHS in each part of the UK needs to commission the necessary ‘extended primary eye care’ services from community optical practices – and at the moment, this happens much less than it should. This paper explains the picture in each part of the UK, and how it needs to change.

We think eye healthcare services in England should be commissioned on as wide a scale as possible, to deliver these benefits to everyone.

The way in which healthcare in England is commissioned changed in 2022 and we recognise that the new ICSs (Integrated Care Systems) offers the potential for greater consistency in provision. There are 42 ICSs across England, covering populations of around 500,000 to 3 million people.

Previously commissioning was through a patchwork of Clinical Commissioning Groups which made their own arrangements. This has led to wide variations across the country. Many commissioners set up services to enable optometrists in the community to monitor patients with conditions like glaucoma, to treat minor eye problems, and to provide post-operative care after cataract surgery. But these are usually on a small scale, and in some areas, there were no extended primary eye care services.

Ideally there should be a nationally commissioned service with every optical practice helping to share the workload. The fees for providing the service would need to be set at an economically viable level, unlike the current NHS sight test fee.

The UK Government changes made to the way healthcare services are commissioned in England, using Sustainability and Transformation Partnerships (STPs) to design services across wider areas, offer a good opportunity to establish extended primary eye care services on a wider scale. The Local Optical Committee Support Unit (LOCSU) has developed model pathways that commissioners can adopt.

What we’re calling for

We want to see extended primary eye care and community monitoring services commissioned at national level in England. If this is not possible, pathways should be nationally endorsed, and services should be commissioned on as wide a scale as possible. Local Eye Health Networks and Eye Health Networks should be properly supported and resourced to enable them to drive forward service improvement.

The AOP launched its Strategy for Optometry – a plan setting out a vision for the future of the profession across the UK. The publication is aimed at elected representatives, NHS commissioners and other key decision-makers and is designed to highlight the key role optometry plays in the NHS, and the scope for it to do even more. The AOP’s Strategy for Optometry lays out where optometrists are qualified and equipped to deliver more NHS work and how this can also relieve pressure on overstretched hospital eye and emergency departments.

The state of play in the other nations

Scotland

In Scotland many eye healthcare services are already included within the Scottish General Ophthalmic Services (GOS) contract, which is wider ranging than in the other UK nations where it largely covers NHS sight tests.

Two new enhanced GOS schemes, covering complex anterior eye conditions and glaucoma, are due to be launched which will provide enhanced funding for appropriately qualified practitioners to treat or monitor patients in the community instead of them being seen in the Hospital Eye Service.

Wales

Wales has outlined an ambitious plan to further increase clinical services and shared care with full details expected around the middle of 2023. It is expected this will allow many patients to be seen outside of traditional hospital settings, more fully utilising the extensive skill set available in optometry.

Northern Ireland

Primary Eyecare Assessment and Referral Service (NI PEARS) has been running successfully across the country since 2018, this is due for review and there is work to pilot another level to the service. This will utilise the IP Optometrists in the community to manage four further sight threatening conditions. 2023 should see cataract post operative management in the community. Project ECHO which enables community Optometrists to manage OHT patients is further extending its role to enable glaucoma medication to be initiated in the community and further free up space in secondary care. The Eyecare Network workstreams are pushing forward to ensure all stakeholders are contributing to ensure eye care is delivered effectively and efficiently.

We continue to work with Optometry Scotland, Optometry Wales and Optometry Northern Ireland to promote optometrists as eye healthcare experts in the community and to encourage the wider roll—out of pilot schemes.

References

Reviewed: November 2022

Read the rest of the AOP position statements.