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Community diagnostic hubs and connectivity

Why we believe that optometry practices with effective IT connectivity are best placed to provide primary eye care including imaging and repeat measures in the community, and that community diagnostic hubs should focus on other clinical areas of need

Optometrist with patient looking at computer screen of his eyes

In October 2020, the Richards Review led by Professor Sir Mike Richards was publishedi. The report, which was originally commissioned by NHS England prior to the COVID-19 pandemic, was asked to consider the case for radical change in the provision of diagnostic services. This scale of the review and its urgency was further amplified by the far-reaching impact of the pandemic in 2020.

In his foreword, Richards concludes: “To deliver the increase in diagnostic activity required now and over the coming years, and to provide safe, patient-centred pathways for diagnostics, new service models are needed.”

The initial scope of the review was to consider the large diagnostic requirements of secondary care such as CT and MRI scanning, but the remit widened to include other specialities with high volumes of patients, including ophthalmology.

Within the report, several recommendations were made with regards to new ways of working, including but not limited to:

  • New pathways
  • Community diagnostic hubs (CDHs)
  • An expanded imaging workforce
  • Improved connectivity and digitisation

With regard to ophthalmology, Richards noted several observations:

  • Ophthalmology is one of the busiest specialties
  • Many patients are missing their optimal recall date due to the backlog and delays
  • A high proportion of patients can have clinical decisions made based upon data and image capture
  • The role optometrists play is important in the initial identification of disease
  • There are poor levels of connectivity between optometry and secondary care

In the review, Richards writes that CDHs can help to solve the challenges of volume and delay within ophthalmology. It is known that large, inner city, ophthalmology teams such as Moorfieldsii are keen to advocate this version of the future as it works well with their patient demographic.

Richards Review on Ophthalmology

The Richards Review includes a number of conclusions relating to ophthalmology. It states: “Over 7.2 million attendances at NHS ophthalmology clinics were recorded in England in 2018/19, accounting for 11% of all outpatient attendances. A significant proportion of the current workload in hospital ophthalmology clinics relates to monitoring of patients with conditions such as glaucoma, age-related macular degeneration or diabetic retinopathy. This could be done in CDHs. A very high proportion of these patients can have clinical decisions made based on clinical data including some form of imaging, by either digital photography or optical coherence tomography (OCT), which is a form of high-resolution imaging of the eye tissues. Attendances are rising by 2.2% p.a. The current service model is under huge strain, with patients not being seen at the optimal intervals and reports of patients going blind while waiting to be seen.

“Ophthalmology has been identified as the first service to be redesigned as part of the NHS Long Term Plan outpatient reform programme. Many patients with both acute and non-acute eye problems are initially assessed by high street optometrists. These provide a very valuable role in case finding and many now provide both digital imaging and OCT services, and can also collect other key clinical information such as eye pressures. However, they are currently poorly linked to NHS ophthalmology services. Patients with possible abnormalities are therefore generally referred to an ophthalmology clinic. If IT links and consistency of equipment and training were better, many of these patients could be assessed by ophthalmologists through virtual clinics, based on data collected by optometrists. Some optometrists could also be upskilled or their existing skills better utilised to make decisions under hospital guidance and governance.”

Elective recovery plan

In February 2022, the Delivery plan for tackling the COVID-19 backlog of elective care was publishediii.

Announced by NHS Chief Executive, Amanda Pritchard and the then Health and Social Care Secretary Sajid Javid, the plan set out a commitment to community diagnostic centres as part of the new elective care recovery plan.

The stated aim was to give patients greater control over their own health and offer greater choice of where to get care if they are waiting too long for treatment. The NHS also said it would be able to “increase capacity to deliver more procedures and scans in each of the next three years, to around nine million more tests and checks by 2025.” Over a three-year period, the aim was for patients to be offered around 17 million more diagnostic tests – an increase in capacity of a quarter compared with the three years prior to the pandemic.

In August 2022, it was announced by the Health and Social Care Secretary, Steve Barclay that over 50 new surgical hubs would open in the UK to “help tackle the COVID-19 backlogs and offer more patients quicker access to care”.

In a statement, Barclay said the decision would “provide at least 100 more operating theatres and over 1,000 beds so people get the surgery they need. The hubs would deliver almost two million extra routine operations to reduce waiting lists over the next three years, backed by £1.5 billion in government funding.”

The Department of Health and Social Care said the hubs would provide high volume low complexity surgery, as previously recommended by the Royal College of Surgeons of England, with particular emphasis on ophthalmology, general surgery, trauma and orthopaedics (including spinal surgery), gynaecology, ear nose and throat, and urology.

Located on existing hospital sites, the stated aim for surgical hubs was “to bring together skills and expertise of staff under one roof – reducing waiting times for some of the most common procedures such as cataract surgeries and hip replacements. These operations can be performed quickly and effectively in one place. Improving quality and efficiency will mean patients have shorter waits for surgery, will be more likely to go home on the same day, and will be less likely to need additional treatment after surgery.”

What are we calling for?

We fully support the Richard review’s conclusion that optometry practices “provide a very valuable role” in delivery eye care, including the detection of eye conditions and disease “using digital imaging and OCT services, and collecting other key clinical information such as eye pressures.” We also support the conclusion that optometry practices “are currently poorly linked to NHS ophthalmology services.”

However, it is our view that the introduction of the CDH model into eyecare is both unnecessary and financially unwise. Optometry practices already have the clinical expertise and diagnostic infrastructure to deliver high quality eye care to patients, including digital imaging. These practices should be the first port of call without the need to use a CDH model.

There are four principles that support our position:

1. Diagnostic equipment is available at volume in optometry practices

The original premise of the review of diagnostic capability was to address the large, expensive, high usage volume pieces of diagnostic equipment that are needed and utilised by many specialities. Based on increasing demand and patient convenience, the review concludes that it is highly likely that all CDHs will provide the following:

  • Imaging: CT, MRI, ultrasound, plain X-ray
  • Cardiorespiratory: echocardiography, ECG and rhythm monitoring, spirometry and some lung function tests, support for sleep studies, blood pressure monitoring, oximetry, blood gas analysis
  • Pathology: phlebotomy
  • Endoscopy
  • Consulting and reporting rooms

The diagnostic equipment commonly utilised in ophthalmology, such as visual field screeners, and OCT are far smaller, less expensive, and most importantly, are near ubiquitous in optometry practices. This provides two distinct advantages: throughput volume and availability, alongside the capital expenditure saving. It is estimated that within optometry practices there are at least 3,000 OCT scanners and around 6,000 practices. Even if 100 new diagnostic hubs were built, equipped with three OCTs per hub, it is our view that a CDH could not feasibly replicate the availability and accessibility of OCT within optometric practices.

2. Patient access needs are met by community optometry practices

Access for patients to healthcare generally is a key challenge. A report by Age UK titled Painful Journeysiv explored the challenges faced by patients in attending hospital appointments. This report identified three key issues, complete with sub issues:

  • Long and uncomfortable public transport journeys
    a. Cuts to bus services
    b. Poor bus accessibility
    c. Bus pass restrictions
    d. Companion travel on public transport
    e. Lack of awareness of public transport options
    f. Underfunding of community transport options
  • Hospital provided patient transport
    g. Tightening of eligibility
    h. Long waiting times for collection and return
    i. Companion travel – hospital transport
  • The cost to older people and their families
    j. Long journeys for specialist treatment
    k. Older drivers and the problems with driving to hospital
    l. Hospital parking
    m. Reliance on family and friends
    n. High cost of private-hire taxis

We agree that some of these challenges may be improved by CDHs. However, the majority will not. CDHs are still examples of large footprint, centralised provision, often located near existing hospitals. In contrast, the 6,000 optometry practices in the UK are in familiar, accessible locations. They are accustomed to providing a patient-centric experience, and reduce or eliminate many of the issues identified by Age UK.

3. Capital expenditure outlay for CDHs to deliver eye care is a poor financial investment

We point to the example of OCT availability within optometry practice across the UK. Taking a conservative estimate of a cost of around £30,000 per OCT machine, our calculation is that the cost to the NHS to replicate this existing volume of OCT scanners would require capital expenditure of around £90m. To fully equip CDHs, that figure would need to include slit lamp biomicroscopes, visual field screeners, tonometers and other general examination equipment found in optometric practices. It is likely that this would at least triple the capital expenditure outlay, and represents poor value for money for the taxpayer.

This example is in contrast to a full-body MRI scanner, which can cost over £500k  and requires significant additional investment to provide and maintain a suitable environment for its use. The equipment occupies large amounts of space and locating it in another location from the main hospital setting releases capacity and space within the hospital estate. 

4. CDHs should not be the workaround for the need to improve basic IT connectivity for optometry practices

In his review of ophthalmology, Richards is critical of the lack of effective IT connectivity. We agree, and note it is a position the optical sector has long advocated. 

Richards adds: “If IT links and consistency of equipment and training were better, many of these patients could be assessed by ophthalmologists through virtual clinics, based on data collected by optometrists. Some optometrists could also be upskilled or their existing skills better utilised to make decisions under hospital guidance and governance”. 

We challenge this assessment. In our view, the existing skills of all, not “some”, optometrists are currently underutilised. Further, what is holding optometrists back is ineffective IT connectivity. It is the lack of IT connectivity that has meant that optometrists have been left with no choice but to make referrals because the details of previous hospital appointments are not available. Improved connectivity would mean every optometry practice can provide increased access for patients. This will help to reduce, and in some cases eliminate, the need for patients to travel significant distances. It will also release capacity in secondary care, enabling the approximately 1.9 million retinal imaging proceduresv to be conducted in primary care with the results transmitted digitally to the hospital for evaluation.

We propose that the solution must ensure all practices conducting sight tests have a safe, simple and secure option to communicate with secondary care colleagues. This can be facilitated by ensuring that all practices and all practitioners including locums have access to NHS mail addresses.

Currently, restricted funding means that there isn’t an easy mechanism for larger practice groups to obtain NHS mail and locums are reliant on benevolent practices to obtain access. By urgently fixing these issues to allow access to this established infrastructure, the requirement in the NHS planning guidance for direct referral from September 2023vi will be more easily met.

We are aware that there are currently multiple emerging solutions to address the more complex image sharing challenges in market. Some of these options are more established and feature-rich than others. To improve collaborative care and to find new ways of working between primary and secondary care, we advocate the following principles:

  • The solution must form part of the contract for services and its costs must be included
  • There must be an API to ensure there is no double keying of information. Double keying introduces the risk of errors and also introduces inefficiencies
  • All providers must be visible on the system to optimise patient care
  • Wherever possible, imaging is delivered in a primary care setting

References

i www.england.nhs.uk/wp-content/uploads/2020/11/diagnostics-recovery-and-renewal-independent-review-of-diagnostic-services-for-nhs-england-2.pdf

ii www.moorfields.nhs.uk/news/moorfields-launches-new-diagnostic-hubs-safely-assess-more-patients-during-pandemic

iii www.england.nhs.uk/wp-content/uploads/2020/11/diagnostics-recovery-and-renewal-independent-review-of-diagnostic-services-for-nhs-england-2.pdf

iv www.ageuk.org.uk/our-impact/campaigning/painful-journeys/

v www.digital.nhs.uk/data-and-information/publications/statistical/hospital-outpatient-activity/2021-22 

vi www.england.nhs.uk/wp-content/uploads/2022/12/PRN00021-23-24-priorities-and-operational-planning-guidance-v1.1.pdf

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