25 April 2019

Implementing the NHS Long Term Plan: Proposals for possible changes to legislation

We have responded to an NHS consultation on proposals for changing legislation.

Our response:

1. Promoting collaboration

The College of Optometrists supports these proposals, which would enable a more flexible collaboration. However, NHS Improvement should have powers to encourage and facilitate collaboration but also powers to prevent structural changes that could work against the interests of patients – for instance, where the end result will be reduced access to eye healthcare in the community.

2. Getting better value for the NHS

In principle, we support these proposals.  However, we recommend all primary care providers to be involved in the decision making process of any new best value test. Commissioners should work closely with NHS England’s Local Eye Health networks (LEHNs), Local Optical Committees (LOCs), the statutory representative bodies for community eye healthcare providers, and Primary Eyecare Companies (PECs). PECs act as the lead for a network of community practices which already deliver NHS eye care services, in a similar fashion to GP Federations, facilitating integrated eye care services in primary and community settings.

PECs are open to all local providers that meet the relevant clinical requirements, promoting patient choice and increasing patient access. They can therefore help commissioners maximise the scope for NHS primary care providers to deliver additional eye healthcare capacity in accessible locations, rather than relying on overstretched hospital eye services – thus supporting the delivery of out of hospital services in local communities as recommended in the NHS Long Term Plan. 

The nature of the ‘best value test’ will be crucial in ensuring that commissioning decisions are rational and transparent. The test will need to be robust and take into account all relevant factors, including demand for services, options to provide the required capacity, and cost-effectiveness of care.

3. Increasing the flexibility of national NHS payment systems

In eye health and care, inflexible national tariffs are currently a significant barrier to the NHS Long Term Plan aspiration of moving more care from secondary to primary care settings. At present, inflexible national tariffs can incentivise secondary care providers to retain simpler care episodes in-house, because the tariff payments for such care are greater than the actual cost of care. In practice, this creates a perverse financial incentive for secondary providers not to move care out into the community, even where it is safe and efficient to do so. 

We strongly welcome the prospect of more local flexibility in setting tariffs. Any new rules and associated guidance should be framed so as to encourage the transfer of care episodes from secondary to primary care where this is clinically appropriate and in patients’ interests, while also ensuring that this sets a good balance between primary and secondary providers. 

In particular, all care episodes must be priced realistically in a way that recognises variations in complexity and in the settings in which care can safely be provided, and drives provision of care in the most appropriate location for the patient. Commissioners should ensure that tariffs for eye care services across secondary and primary care are set on the basis of evidence and information from the relevant care delivery setting. A reduction or increase in the hospital eye service tariff for specific types of episode, following these reforms, should not automatically influence the equivalent community tariff. 

The proposal to enable the national tariff to include prices for ‘section 7A’ public health services will apply to diabetic eye screening programmes. We support the implementation of this proposal, and the proposals discussed above on promoting collaboration and getting better value for the NHS, to diabetic screening.

4. Integrating care provision

In principle, we support the proposed change. It would help commissioners and providers working together to develop new models of integrated care that meet the needs of patients in their community. However, we strongly recommend that commissioners include optometrists – not just GPs – in the planning of new integrated services, as well as their delivery. That will help ensure that new services are designed around the real needs of patients, which will include growing eye healthcare capacity for an ageing population.

Any new NHS trusts created under the proposed power should replace rather than supplement existing structures as far as possible, to avoid adding unnecessary management costs.

5. Managing the NHS’s resources better

In principle, we support these changes. They would enable NHS Improvement to drive cross-system efficiencies. However, as noted in our response to proposal 1 above, NHS Improvement should prevent structural changes that could work against the interests of patients.

In addition, community eye health practices have over 5000 well-equipped NHS premises at their disposal, which could take on a large amount of routine non-medical ophthalmology care from hospitals without the need for significant capital investment. This would allow more money to be invested in capital expenditure where there are no suitable alternatives.

6. Every part of the NHS working together

We would support these changes, as long as:

  • decision-making committees include optometrists and are properly representative of local patient needs including eye healthcare, so they can make informed decisions on local healthcare priorities
  • the provisions to manage potential conflicts of interest are robust and effectively policed
  • core primary care contracts, such as the General Ophthalmic Services (GOS) contract, are retained at national level to ensure an adequate foundation level healthcare offer across the population.

We also recommend that new funding to support joint working is distributed fairly to those involved, and not directed only to GP practices.

7. Shared responsibility for the NHS

We strongly support this proposal. A shared duty on these lines would encourage all those involved in the provision of local healthcare services to seek the most efficient way of providing high-quality healthcare and public health services. This should in turn help to drive the Long Term Plan aspiration of delivering more healthcare in primary settings. 
Primary eye care contractors should be fully involved in this shared planning. Although the NHS eye healthcare budget is small in the context of overall NHS spending, community optical practices perform 13 million NHS sight tests in England each year, as well as offering many extended NHS services.

The consultation refers to NHS bodies such as CCGs having shared responsibilities. If a new shared duty is to work effectively, we think it should also apply to other commissioning bodies such as local authorities.

8. Planning our services together

In principle, we support the proposal that NHS England should be able to promote more joined-up services, and it should be expected to make full use of this power.
The consultation (para 65) notes that NHS England currently commissions a range of services including primary ophthalmic services, and that it wants the planning and funding of these to be joined up with other local services.

The General Ophthalmic Services (GOS) currently commissioned by NHS England are NHS sight tests in community and domiciliary settings. These services are clearly and narrowly defined, and are delivered by almost all community optical practices in England – ensuring a standardised foundation-level eye healthcare offer across the population. 

There is a great deal of scope to augment these GOS services with other primary eye care services, such as the Minor Eye Care Services (MECS) which are already commissioned by many CCGs and have the potential to further reduce demand on secondary care if commissioned more widely. 

However, we strongly recommend that any new joint commissioning of primary care services should avoid any shift to local commissioning of core primary care contracts that are currently commissioned nationally. For example, the GOS contract provides around 13 million NHS sight tests a year in England. This is a high quality national service which is delivered in readily accessible high street locations by thousands of community optical practices, while increasingly integrated with GPs and secondary care.  

Moving to local commissioning of such services would create unwarranted variation in core primary care services, and could reduce provision in some areas, damaging patient care. It would also be highly inefficient and disruptive, adding significantly to transaction costs for no benefit.

9. Joined-up national leadership

We support these changes as they would reduce unnecessary cost in the management of the NHS. However, it is important that any further organisational changes do not distract NHS England from its key task of implementing the Long Term Plan.

Submitted: April 2019

This response draws on material in the AOP’s response to this consultation.

Related further reading

Claire Moulds examines the impact of a power of attorney on the patient relationship.

Research, including work carried out in high-street optometry practices, is driving innovation in clinical practice and at a policy level, writes Mark Gould.