College urges eye health to be prioritised in its response to NHS 10-Year Plan

The College of Optometrists supports the government’s three shifts for the NHS in England as these reflect the strength of primary eye care.

We would like to see the 10-Year Health Plan commit to transforming NHS eye care services to end the current eye care crisis, clearly setting out how the NHS must ensure patients receive the care they need at the right time and the right place, through the government’s three big shifts:

• Hospital to community: Rolling out and enabling access to NHS funded enhanced primary eye care services nationally will allow hospitals to focus on the most serious eye conditions and emergencies.
• Analogue to digital: Prioritising and investing in better connections between primary and secondary eye care will improve patient outcomes, reduce referrals and avoid the need for repeat diagnostic tests. 
• Sickness to prevention: Encouraging regular eye examinations with an optometrist as an important healthy lifestyle behaviour will help preserve sight and keep people living independently for longer, benefitting individuals, the NHS and the wider economy.

There are over 14,000 optometrists in England. They are registered health professionals trained to examine the eyes to detect defects in vision, signs of injury, ocular diseases or abnormality and problems with general health, such as high blood pressure or diabetes. Those in primary care make a health assessment, offer clinical advice and prescribe spectacles or contact lenses. They can also treat and manage a wide range of eye conditions. Primary eye care practices are equipped with modern examination and diagnostic tools and provide prompt, safe and high-quality eye care.  Optometrists are a key part of the NHS workforce, providing around 13 million NHS-funded sight tests in primary and domiciliary settings across England each year¹.

Optometrists in primary care have the core clinical skills required to provide more NHS services than most are currently commissioned to do. They can deliver safe and timely eye care to all patients closer to home to reduce the reliance on local GPs, cut NHS ophthalmology waiting times and enable more people to live independently with the best vision possible. 

The government’s three shifts can benefit patients and the wider NHS by reducing pressures on hospital eye services and better aligning overall NHS capacity and funding to meet growing patient need.

Optometrists working in primary care are well-placed to provide routine, enhanced and shared eye care services closer to home, and to reduce the backlog of delayed outpatient appointments. This can be achieved through commissioning services such as glaucoma repeat measures and community minor and urgent eyecare services (CUES) using core optometric competences. With further  higher qualifications and/or independent prescribing, optometrists can offer an even wider range of specialist eye care services and  manage patients with more complex needs within primary care, working closely with secondary care colleagues.

In  other UK nations, optometrists already play an essential role in reducing the burden on GP practices and reducing pressures on hospital ophthalmology departments, and make a significant contribution to reducing sight loss.

The core capabilities of optometrists create a flexible and ready workforce who can provide safe and timely eye care to all patients closer to home.

Optometry has already embraced  advances in imaging technology, such as optical coherence tomography (OCT), which have enabled optometrists to spot changes in eye health at an earlier stage.

We would like to see included in the 10-Year Health Plan the need for improved Digital/IT connectivity between primary and secondary care settings as a key enabler to transform eye care service delivery, such as allowing electronic referrals. In addition, the development of DICOM standards will drive interoperability of digital systems enabling seamless sharing and viewing of patient images digitally across systems and between primary and secondary care settings. This will improve the ability to make swift and efficient diagnosis, referral and treatment decisions².

Although the risk of developing many eye conditions such as cataracts and age-related macular degeneration (AMD) increases with age, when it comes to eye health, prevention is key. 50% of moderate to severe vision impairment across Western Europe is preventable³ and changes in lifestyle can reduce the risk of developing poor eye health and sight loss⁴. Worse eye health is also linked with indicators of inequality such as ethnicity and deprivation⁵.

Primary care optometrists are in a good position to deliver public health messages on lifestyle choices due to their  location and high levels of patient coverage. They play a critical role in primary and preventative healthcare for patients attending for eye examinations, who may not be in regular contact with other health professionals. Regular eye examinations can identify both eye problems and other wider systemic diseases such as high blood pressure, high cholesterol and patients that may have diabetes or are pre-diabetic. Optometrists also provide advice, treatment and referral to manage these. 

[1] General Ophthalmic Services Activity Statistics England, year ending 31 March 2023

[2] Digital Imaging and Communications in Medicine standard: DICOM

[3] Bourne RRA, Jonas JB, Bron AM on behalf of the Vision Loss Expert Group of the Global Burden of Disease Study, et al British Journal of Ophthalmology 2018;102:575-585

[4] Barbara E.K. Klein, Ronald Klein, American Journal of Ophthalmology, Volume 144, Issue 6, 2007, Pages 961-969.e1, ISSN 0002-9394

[5] Atlas of variation in risk factors and healthcare for vision in England, PHE, 2021 

Hospital eye services (HES) and  GPs in England are under increased pressures. Demand for NHS eye care services had exceeded capacity. Ophthalmology is the largest outpatient specialty in the NHS, with 7.5 million appointments in England in 2021-22⁶, and a 30-40% increase in demand for eye services predicted in the next 10 to 15 years⁷. 

Over 611,000 people are on NHS England waiting lists to begin treatment for ophthalmology, making  it one of the largest contributors to the NHS backlog⁸ – and this number is set to grow with an ageing population.

Delays to treatment can have devastating consequences for individuals, families and communities. Patients are not being seen within clinically appropriate timeframes, which leaves them at risk of avoidable and irreversible sight loss.

We must unleash the potential of primary eye care to cut NHS waiting times and improve patient outcomes by enabling optometrists to provide more care to patients closer to home.

Optometrists have the necessary core clinical skills to provide more NHS services than they are currently commissioned to do. If commissioned, they  can deliver more safe and timely eye services to patients  to help reduce the reliance on local GPs, cut NHS waiting times and enable more people to live independently. Many optometrists have additional higher qualifications, including the ability to prescribe medications, and can also manage patients with more complex eye conditions. However, our health system in England is not consistently utilising their skills to their full potential.

Commissioners must recognise and utilise the full core skills and competences of primary care optometrists, as well as those with independent prescribing and higher qualifications, to reduce unnecessary referrals to secondary care, and increase capacity to manage low risk patients with long-term eye conditions outside of the hospital.

To meet the growing demand for accessible and timely care for more complex sight-threatening conditions, due to an ageing population, we also need increased numbers of optometrists with independent prescribing and/or higher qualifications in specialist areas of practice (such as glaucoma and medical retina). The biggest barrier to achieving this is access to clinical learning placements. Innovative solutions are required to address the significant bottlenecks and develop the infrastructure necessary for improved placement capacity. The College of Optometrists would welcome an opportunity to share our expertise in pre-registration placement programmes to design such solutions.

Optometrists should be established as the first point of contact for patients with an eye concern, instead of their GP, in addition to the vital sight testing and eye examination services they already provide. 

As first contact healthcare practitioners, optometrists would be best placed to provide prompt accurate assessment, diagnosis and management that would reduce GP appointments and avoid unnecessary referrals into secondary care. They would build effective multidisciplinary working between primary and secondary care to tackle the current postcode lottery of access to specialist eye care and reduce health inequalities. This will ensure patients can more quickly receive the right care they need and will free up NHS hospital eye services to treat patients in need of more complex or urgent care. The College of Optometrists and The Royal College of Ophthalmologists have developed a joint vision to support the commissioning of safe and sustainable eye care services that meet the needs of all patients, improving patient care and outcomes. Our vision reflects the current scale of work increasingly being undertaken in primary eye care and emphasises the need for enhanced digital two-way communication and image sharing between all health professionals involved⁹.

Every patient in England should have access to the following enhanced NHS primary eye care services based on clinical need:

• Community Minor and Urgent Eye Care Service (CUES) or Minor Eye Conditions Service (MECS)
• Referral filtering services – including access to advanced diagnostics
• Cataract – pre/post operative support pathway
• Glaucoma care – including referral refinement and managing low risk patients diagnosed with glaucoma
• Medical retina care – including referral filtering and a monitoring service for patients diagnosed with retinal disease

The benefits of enhanced primary eye care such as CUES are recognised^10,11, but to date these have been locally commissioned, resulting in inconsistent availability across England. MECS and CUES provide a good example of how optometrists can take on wider clinical roles as first contact providers of eye care services and relieve pressure on other parts of the NHS.

An economic analysis of MECS schemes has found that the initiative reduced hospital referrals while providing replacement services at a lower cost. The research analysed the volume of patients referred and the cost of treating them in the three London boroughs of Lambeth, Lewisham and Southwark between April 2011 and October 2014. MECS schemes were operating in both Lambeth and Lewisham, while Southwark did not have a MECS scheme and was used as a control. The study found that GP referrals to hospital ophthalmology were reduced by 30.2% in Lambeth when compared to Southwark, while in Lewisham the reduction in referrals was 75.2%. Costs increased by 3.1% in Southwark during the time of observation. Over the same period, costs increased by less in Lambeth (2.5%) and fell by 13.8% in Lewisham¹².

The lack of capacity in the hospital eye services for glaucoma patients has been highlighted in a report from the Healthcare Safety Investigation Branch¹³. An estimated 22 people a month suffer severe or permanent loss of sight due to delays in follow-up appointments, and this has been attributed to insufficient capacity within HES¹⁴. This could be improved by setting up referral refinement schemes within primary care.

The Cambridge community Optometry Glaucoma Scheme (COGS) was initiated in 2010, where new referrals for suspected glaucoma are evaluated by community optometrists with a special interest in glaucoma, with virtual electronic review and validation by a consultant ophthalmologist. Of the patients, 46.6% were discharged at initial assessment and 5.7% following virtual review. Evaluation of the scheme demonstrated it was a safe and effective way of evaluating glaucoma referrals in the community and reducing false-positive referrals to HES. The scheme was subsequently extended to include the review and management of patients who needed long term glaucoma care¹⁵. A 2013 comparison of four glaucoma referral refinement schemes showed that only 14.1% of referred patients were discharged by the HES after their first visit, compared to 36.1% patients who had been referred by optometrists who were not part of referral refinement schemes¹⁶. 

Such referral refinement schemes can be expanded to include primary care-based glaucoma monitoring and management for low risk and some medium-risk patients. This increases secondary care capacity both by reducing new referrals and reducing the number of people requiring lifelong glaucoma monitoring needing to be seen in hospital. Optometrists with a higher qualification in glaucoma are well placed to monitor or manage these patients¹⁷.  Evaluations of two such schemes show that patients have a lower rate of visual field deterioration and that 88% of OHT patients could be managed in the community^{18, 19}.

In Staffordshire, local NHS contractors and practitioners in the area have worked collaboratively with NHS commissioners, hospitals and ICBs to improve patient eye care inequalities, hospital eye services and GP pressures. Using optometrists’ core competences and higher qualifications, optometry-led enhanced services provided in multidisciplinary teams have been safely commissioned (MECS/CUES, glaucoma repeat measures, glaucoma enhanced case finding, pre & post cataract examination and paediatric shared care). This has shifted more care from hospital to community, freeing up acute care to deal with sight-threatening eye care conditions in a timely manner. In 2023-2024, 78.7% of patients seen for glaucoma repeat measures, 63.9% of patients seen for glaucoma enhanced case finding and 73.5% of patients seen for CUES did not require referral to the hospital and were safely managed in primary care. Patient anxiety was also reduced²⁰.

Such schemes are clear examples of how optometrists can successfully provide NHS enhanced services safely and effectively within primary care setting, working in collaboration with secondary care colleagues to reducing the burden on NHS waiting times and improving patient’s outcomes.

However, the majority of citizens in England do not have access to community-based schemes to manage their eye conditions. 

Despite the potential of primary eye care to alleviate the pressures on the hospital eye service, inconsistent commissioning and fragmented approaches have led to a postcode lottery in service availability, perpetuating inequalities in access to care. Pathways and services should be integrated at geographies larger than single hospital level, where possible. There should be equity of access to enhanced services developed on the basis of population need. Eye care services also need to be appropriately and equitably funded to meet growing patient needs across primary and secondary eye care.

There is a  lack of representation and effective involvement of the full range of primary and community healthcare professions, including optometrists, at Integrated Care Board (ICB) level to inform commissioning decisions. This is another major barrier preventing improved integration between primary and secondary eye care.

As the Fuller stocktake report recognised, a major delivery challenge for ICBs is how to actively involve primary care in strategic service planning [21].  All primary care providers, including optometrists, should be directly involved in the design, delivery and leadership of more integrated services for local populations. Having optometric representation would ensure all patients’ needs are considered, eye health is effectively included in general health decisions and improve opportunities for more integrated and mutually supportive services. It would also ensure the entire eye care workforce is  recognised and their skills effectively used to  increase capacity across systems.

We strongly recommend that commissioners include optometrists in the planning and delivery of new integrated services. Primary care optometrists can help commissioners deliver additional eye healthcare capacity in accessible locations, rather than relying on overstretched hospital eye services, supporting the delivery of out of hospital services in local communities.

There is an urgent need to improve and streamline the collection and sharing of eye care data within NHS systems. There is currently no shared understanding or consistency of the data that is collected, which metrics are useful and how data could be best used for performance monitoring, evaluation and research.

Better quality data across eye care pathways is essential. Data helps commissioners understand local demand for eye care and identify any unmet need. Without high quality data, developing innovative approaches to preventing sight loss is severely hampered.

We need to have an accurate understanding of a population’s needs in order to plan effective and appropriate eye care services. The existing data in the General Ophthalmic Services (GOS) payments systems and hospital clinical systems needs to be collated and used to best inform ICS planning and commissioning. We would then like to see a move towards better quality and more comprehensive data collection at ICS level, which can be used to inform both local and national primary care service provision. 

There is also an urgent need to understand eye care workforce requirements now and in future, in order to meet patient need and improve outcomes. As part of our Workforce Vision²², The College of Optometrists and its partners have developed a UK Eye Care Data Hub to estimate the current eye care workforce and eye disease prevalence or incidence, and to model future trends over time. It has been designed to support commissioners and designers of eye care services to identify future population eye care needs and optimise the existing eye care workforce. This knowledge should help commissioners better meet eye health needs, identify priorities for future workforce education, training and development and support the development of new models of care²³.  

[6] NHS Digital, Hospital Outpatient Activity, 2021-22, Main Specialty. 

[7] The Royal College of Ophthalmologists, Workforce census 2018. 

[8] NHS England. Consultant-led Referral to Treatment Waiting Times for Incomplete Pathways. December 2023

[9] The College of Optometrists and The Royal College of Ophthalmologists, February 2024. Our vision for better integrated eye care services

[10] Evgenia Konstantakopoulou et al., BMJ Open Ophthalmology 2018;3:e000125

[11] Swystun AG, Davey CJ. BMC Health Serv Res. 2019 Aug 29;19(1):609. doi: 10.1186/s12913-019-4448-8. PMID: 31464616; PMCID: PMC6716842.

[12] Mason T, et al. BMJ Open 2017;7:e014089. doi: 10.1136/bmjopen-2016-014089

[13] Healthcare Safety Investigation Branch, Lack of timely monitoring of patients with glaucoma, 2020.

[14] Foot B, MacEwen C. Eye (Lond). 2017;31(5):771-775.

[15] Keenan J et al., Cambridge community Optometry Glaucoma Scheme. Clin Exp Ophthalmol. 2015;43(3):221-227.

[16] Ratnarajan G, et al. BMJ Open. 2013 Jul 21;3(7):e002715.

[17] The College of Optometrists and The Royal College of Ophthalmologists, Designing Glaucoma Care Pathways using GLAUC-STRAT-FAST 

[18] Mushtaq, Y. et al. Eye 36, 555–563 (2022). 

[19] Mandalos, A. et al.  Eye 26, 564–567 (2012)

[20] Staffordshire Local Optical Committee 

[21] NHS England, Next steps for integrating primary care: Fuller stocktake report, May 2022

[22] The College of Optometrists, A workforce vision for the UK

[23] The College of Optometrists, UK eye care data hub

Primary eye care has already embraced technology and invested in advanced digital assessment and diagnosis tools, such as OCT. We expect further significant technological changes in the next decades, which could transform the role of the optometrists and improve patient’s outcomes. The most significant will be the use of artificial intelligence (AI) to diagnose eye disease. A partnership between Moorfields Eye Hospital and DeepMind Health has already shown that AI can help ophthalmologists and optometrists to diagnose eye disease accurately^24,25. 

The issue is that fragmented, costly and complex NHS IT systems create barriers to making the most of all that primary eye care has to offer.

Good patient care requires effective communication between and within primary, community and secondary care to support improved patient experience and outcomes, for example to enable effective referrals and shared care provision. Digital/IT connectivity is a key enabler to transform eye care service delivery, but a major barrier to achieving this is a lack of IT connectivity provided to primary eye care practices.

Many optometrists providing NHS-funded primary care do not have access to the NHS.net portal, cannot access electronic patient records and cannot digitally refer to their local hospital eye service. Poor digital connectivity prevents optometrists and ophthalmologists from working better together and improving patient outcomes from simple improvements such as referral feedback through to shared management of patients. Many digital images (including OCT scans) cannot be shared between optical practices and the hospital, meaning that patients must have the same images taken again at the hospital after referral. This lengthens delays in diagnosis and treatment, and increases unnecessary costs for the NHS.

Upgrading IT infrastructure and improving digital connectivity will lead to more effective communication between healthcare professionals. We need effective, two-way IT connectivity between primary and hospital eye services, and GPs. This would ensure timely, secure and effective communication to improve patient care, and also facilitate feedback between multidisciplinary professionals to aid learning and improve clinical decision making.

There are currently some electronic eye-care referral systems (EeRS) in various regions that link primary and community care practices and hospital eye-care services. However, it is unclear how these will link into the national electronic referral system (eRS) programme that NHS England is developing.

There is an urgent need for a joined-up, national approach to electronic referral systems across eye care. This must be implemented in a planned and systematic fashion with appropriate levels of funding to ensure roll-out is safe and effective and does not put patient safety at risk. These risks include potential digital isolation of patients and practitioners and lack of safety-netting – which is essential in case of IT failure.

While we recognise that funding arrangements and timescales for implementation should be agreed collaboratively with local stakeholders, national engagement and coordination  are important to achieve optimal primary eye care IT connectivity.

There is also the need for ensuring digital clinical image interoperability. Currently, there are several digital systems available to take and review ophthalmic clinical images within hospital trusts and optical practices. However, the historical lack of agreed interoperability standards means most of these systems and image files are incompatible with one another.

Clinical images are increasingly offered in primary and community eye care settings to detect and monitor eye disease. They can also help improve referrals to secondary care  enhancing patient outcomes within shared care pathways. However, incompatible systems mean images often need to be taken repeatedly wasting time and resources, and causing delays in diagnosis and access to timely treatment leading to avoidable sight loss. This also causes increased stress and anxiety to patients.

Standardisation of digital imaging in eye care will allow: 

• seamless sharing and viewing of patient images digitally across systems and between primary and secondary care settings
• improved ability to make swift and efficient diagnosis, referral and treatment decisions
• facilitated use of artificial intelligence through deep learning to enhance clinical decision making

The College of Optometrists and the Royal College of Ophthalmologists are co-leading a digital imaging Task and Finish group with NHS England. This brings together healthcare professionals, the manufacturing industry and sector stakeholders to develop a set of DICOM standards that will drive interoperability of digital systems. 

The adoption of digital image sharing standards by all device manufacturers will support better image sharing. This will ensure more efficient patient referrals, and reduce delays in diagnosis and treatment. 

[24] De Fauw et al. Nat Med 24, 1342–1350 (2018)

[25] Yim, J. et al. Nat Med 26, 892–899 (2020)

Sight loss has a significant impact on all aspects of life, and more still needs to be done by the Government and the NHS to reduce preventable sight loss.

250 people start to lose their sight every day²⁶. More than two million people in the UK live with sight loss that is severe enough to have a significant impact on their daily lives, such as not being able to drive or find employment and suffer increased social isolation²⁶. They also require additional support from community and social services. By 2050, this number is projected to increase to 4 million²⁶. Sight loss costs the UK economy £25 billion a year. By 2050, these costs are expected to rise to £33.5 billion a year²⁷. Reducing the prevalence of eye conditions by 1% a year could save the UK economy £3 billion, and by 2050, these savings are expected to be £9.5 billion²⁸.

It is vital for the public to understand the importance of regular eye examinations, which are crucial in detecting early signs of eye disease and other health problems. We would like to see more interventions that encourage people to attend for regular eye examinations as part of a healthy lifestyle and to prevent worsening eye (and systemic) health.

We know that eye health is linked to several public health issues, including smoking, obesity, alcohol use, mental health, and disease prevention:

• Smokers are up to four times more likely than non-smokers to develop age-related macular degeneration (AMD). AMD is a major cause of vision loss and can lead to blindness²⁹
• Poor diet, obesity and type 2 diabetes have been identified as heightened risk factors for a range of sight-limiting eye conditions including glaucoma, cataracts, AMD and diabetic retinopathy³⁰
• Visual issues can exacerbate other long-term health conditions, such as dementia³¹ and depression³²
• Sight loss can cause social isolation, increase a person’s risk of falling and create a fear of movement, which can in turn increase frailty. Older people with eye diseases are three times more likely than those with good vision to limit activities due to fear of falling³³

Regular eye examinations and enhanced primary care services not only prevent sight loss but also reduce broader health risks and associated costs. Public health campaigns encouraging routine eye exams could help detect systemic conditions like diabetes and hypertension earlier, improving overall outcomes and reducing the financial burden on the NHS.

A good case study is the Healthy Living Optical Practice initiative, which started in Dudley. Through the scheme, primary eye care professionals offer a range of health-related advice, including NHS health checks, smoking cessation services, alcohol screening and weight management. Patients can also receive lifestyle advice and, if necessary, referral into other support services. Initial results from the pilot proved to have a positive effect and the scheme was rolled out in Manchester, Nottinghamshire and Derbyshire³⁴.

A pilot stroke prevention study was set up in East Cheshire, to determine if primary eye care practices could identify patients with undiagnosed atrial fibrillation. Patients aged 60 and over were screened. The pilot demonstrated that low cost screening in primary eye care reduced the burden on GPs and identified a number of people at risk of stroke, enabling them to seek appropriate treatment and reducing the negative impact of a stroke on their lives and to the wider health and social care system³⁵. 

The NHS is trialling blood pressure checks at dentist and optometry appointments to help find people at hidden risks of stroke or heart attacks. The scheme which will be up and running in the coming months follows the success of NHS community pharmacy blood pressure checks, which has delivered more than a million checks in the last year and allows people to keep on top of their risk of cardiovascular disease without the need for an appointment. As high blood pressure usually has no symptoms, it is estimated that 4.2 million people in England have the condition without knowing it. There are 15 ICBs across England taking part in the scheme. More than 60 clinical practices will trial the new approach and its expected over 100,000 blood pressure checks could be delivered over the next 12 months³⁶. 

The risk of developing many eye conditions increases with age, but worse eye health is also linked with indicators of inequality such as ethnicity and deprivation³⁷. 

There is evidence that people living in socio-economically deprived areas face more barriers to accessing primary eye care, and therefore present later to hospital eye services³⁸. It is important that commissioned primary eye care services exist in non-urban and more deprived areas, and local residents supported to access both regular eye examinations and enhanced eye care services, to help prevent sight loss and improve vision and related wider health outcomes. 

[26] RNIB. (2021). Key statistics about sight loss

[27] Pezzullo, L. et al. BMC Health Serv Res 18, 63 (2018)

[28] Fight for Sight. Time to focus. 2020. 

[29] Macular Society. Smoking and sight loss

[30] Bourne RRA, Jonas JB, Bron AM on behalf of the Vision Loss Expert Group of the Global Burden of Disease Study, et al British Journal of Ophthalmology 2018;102:575-585

[31] Social Care Institute for Excellence. Caring for those with dementia 

[32] Demmin DL, Silverstein SM, 2020. Visual Impairment and Mental Health: Unmet Needs and Treatment Options, Dovepress 

[33] The College of Optometrists, The importance of vision in preventing falls 

[34] Dyoss M., Asif S., Improving eye health through community optical practice, 2016

[35] LOCSU. Primary eye care support for stroke prevention in Cheshire 

[36] NHS England. Blood pressure checks at the dentist and optician to catch those at risk of heart attacks and strokes 

[37] Atlas of variation in risk factors and healthcare for vision in England, PHE, 2021 

[38] Shickle D, et al. Public Health. 2015 Feb;129(2):131-7

• Ensure NHS CUES and other enhanced services are available in every ICB across England – see response to Q2.
• Create a national pathway for glaucoma care that makes better use of primary care optometrists to provide repeat measures, referral refinement and management of low to medium risk patients – see response to Q2.
• Encourage people to attend for regular eye examinations with an optometrist as an important healthy lifestyle behaviour – see response to Q4.
• Ensure eye care services are appropriately and equitably commissioned and funded to meet growing patient needs across primary and secondary eye care – see response to Q1.
• Ensure all eye care services and enhanced services are designed and commissioned based on population need and eye care workforce and skills available – see response to Q4.
• Roll out access to NHS.net to all primary eye care practices to ensure a robust, secure mechanism of communication between primary and secondary care – see response to Q3.
• Invest in innovative solutions to address the bottlenecks in clinical placements available for optometrists taking independent prescribing and higher qualifications – see response to Q2.

• Ensure optometry-led enhanced and shared eye care services are consistently commissioned across England based on clinical need and delivered to national specifications. These services must be funded and promoted to patients and the public, and optometrists should be established as first contact healthcare practitioners in England – see our response to Q2.
• Agree and implement DICOM standards for ophthalmic imaging, to allow a seamless interface and joined up patient care – see response to Q3.