The case for change: alignment with commissioning priorities
Integrated, local care
Evidence shows that optometrists can safely undertake referral filtering, monitoring and management of low-risk ocular hypertension (OHT) and stable glaucoma, with clinical decision-making comparable to hospital-based care. Optometry-led glaucoma referral filtering services (GRFS) and community shared care pathways enable care to be delivered closer to home, while remaining fully integrated with secondary care through agreed
protocols, oversight and governance. These pathways strengthen collaboration between primary and secondary care, improve access and choice for patients, and make better use of the wider eye care workforce. This supports local models of care and reduces over-reliance on hospital outpatient clinics for stable and low-risk activity.
Recovery and transformation to sustainable outpatient care
GRFS directly support outpatient efficiency by refining referrals to hospitals. Across multiple UK models, evidence demonstrates that these services:
- substantially reduce false-positive referrals and first-visit discharges
- prevent 40-75% of onward referrals to HES, depending on service design
- release significant volumes of outpatient capacity
Enhanced case-finding, referral refinement and virtual review models show particularly strong performance, with high agreement between optometrists and ophthalmologists and very low false-negative rates. Some services have released thousands of HES appointments. Shared care pathways further support outpatient recovery and transformation by shifting long-term follow-up of stable and low-risk patients out of hospital settings. This reduces follow-up backlogs and enables HES to prioritise patients with complex disease or high risk of vision loss: directly supporting elective care recovery and safe waiting list management.
Prevention and early diagnosis
Given that glaucoma-related vision loss is irreversible, prevention and early diagnosis are critical. GRFS improve early detection by:
- increasing the proportion of true-positive referrals reaching HES
- reducing delays caused by unnecessary hospital appointments
- supporting timely escalation for those at genuine risk
In particular, repeat measures services allow equivocal findings from sight tests to be clarified and have been shown to avoid up to three quarters of suspected glaucoma or ocular hypertension referrals without compromising safety. By improving referral quality and timeliness, these pathways reduce the risk of preventable sight loss and associated long-term health and social care costs.
Population health management and reducing unwarranted variation in England
Access to GRFS and shared care pathways is currently inconsistent across England, contributing to unwarranted variation in referral quality, waiting times and outcomes. This variation disproportionately affects people in deprived communities and ethnic minority groups, who are at higher risk of advanced disease at presentation. Standardised commissioning of community-based glaucoma pathways would enable integrated care boards (ICBs) to achieve population health management principles by:
- planning services around population need and risk
- targeting areas with poor access or late presentation
- reducing postcode variation in pathways and outcomes
These models provide system leaders with practical levers to improve equity, consistency and outcomes at scale.
Existing glaucoma services in Northern Ireland, Scotland and Wales
Health policymakers should maintain existing GRFS in Northern Ireland (NI), Scotland and Wales, making full use of the optometry workforce and supporting those with advanced qualifications to deliver more care closer to home. Roll out of the new Community Glaucoma Service in Scotland and WGOS4 glaucoma monitoring services in Wales should continue to be supported. Shared care pathways beyond OHT patients should be introduced in NI to help improve patient outcomes.
Regular clinical audits and the publication of safety and patient-reported outcomes are required to grow the evidence base for delivering safe and effective care.
Optimal use of resources
The evidence base demonstrates that optometry-led GRFS and shared care pathways are safe, effective and acceptable to patients, with outcomes comparable to hospital care for appropriate cohorts. Both referral filtering and shared care models provide long-term system benefits, including released hospital capacity, reduced delays, improved flow and better outcomes for high-risk patients. These pathways ensure care is delivered in the most appropriate setting, maximise workforce skills, and support long-term system sustainability in the context of rising demand.
Patient experience and wider benefits
Patient satisfaction with both GRFS and shared care pathways is consistently high. Patients value shorter waiting times, reduced travel, greater convenience and improved communication. Community-based care also offers environmental benefits through reduced travel and lower carbon emissions, aligning with broader national environmental sustainability goals.
Conclusion
The evidence is clear that maintaining hospital-only glaucoma pathways is not viable. Rising demand, constrained hospital capacity and unwarranted variation create increasing risks to patient outcomes and system sustainability. Optometry-led glaucoma referral filtering services and shared, community-based pathways for low-risk patients offer a proven, scalable solution that aligns directly with health systems’ priorities for integrated, local care, recovery of outpatient care, prevention and early diagnosis, population health management and optimal use of resources. These models are not an incremental improvement but a strategic shift in how long-term eye conditions should be managed: releasing hospital capacity, protecting patients from avoidable harm and creating a more resilient eye care system fit for an ageing population.
Evidence review
Conclusions
UK nations have a significant opportunity to help manage the increasing number of glaucoma cases and limited HES capacity58. This can be achieved by supporting all optometrists to use their core skills to prevent referral initiation, and utilising the capacity afforded by optometrists with higher qualifications in primary care to further prevent onward referral of suspected cases to HES and manage low-risk glaucoma cases in the community. While such services are being rolled out in Wales and Scotland, full coverage is still to be achieved (at the time of writing) and full shared care services are yet to be commissioned in Northern Ireland. England has variable and limited availability of both GRFS and shared care pathways. Therefore, there are still opportunities to improve HES capacity and patient outcomes.
It is evident that GRFS and community shared care pathways are safe and effective, significantly reducing the burden on HES, with clinical quality comparable to hospital-based clinicians. Given the current ophthalmologist workforce shortages and HES capacity issues, these pathways release HES capacity to focus on patients in greatest need, reduce waiting times and help prevent avoidable sight loss due to delays in accessing glaucoma treatment. Patients benefit from a wider choice of locations for services, reduced travel time and distance, and have a high level of satisfaction with the care provided. This aligns with broader environmental sustainability needs and broad national health systems’ goals of moving care into the community and improving integration between primary and secondary care. Local planning with a whole system view to selectively commission community enhanced case-finding/referral services and shared care management pathways will enable a more resilient national eye care system fit to meet the growing needs of each nation’s aging population.
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