4 February 2020

Improving patient safety and experience when referring to hospital in England

Eye Care Services are experiencing increasing pressure due to greater patient need. This can lead to delayed treatment for patients who need hospital care.

Up to 22 patients a month across the UK might be losing vision because of delayed treatment and follow-up appointments ii. The January 2020 Healthcare Safety Investigation Branch (HSIB) report on Lack of Timely Monitoring of Patients with Glaucomaiii centres on the serious risks to patients’ sight caused by delays in glaucoma appointments. This and the Getting It Right First Time (GIRFT) Ophthalmologyiv  report both highlight that urgent changes are needed in eye healthcare.

We call on NHS England leaders to work with professional and patient eye care organisations to improve the models and funding of eye care services to protect patients.

In the absence of enhanced services and funding, commissioners can still work to improve integration of services, and care providers can collaborate to improve the way we use existing resources. For example, ensuring that only patients whose conditions need secondary care input are seen in hospital will improve capacity for patients with serious and sight-threatening conditions. This is likely to have a positive impact on patient waiting times and reduce unnecessary healthcare expenditure. 

The Royal College of Ophthalmologists, The College of Optometrists and the Association of Optometrists are committed to working together to promote cooperation and best practice. Our joint statement sets out the ways that commissioners, hospital eye departments, individual ophthalmologists and optometrists can already contribute to improving eye care service capacity. 

NHS England leaders and commissioners 

Commissioners and NHS leaders can make the most significant contribution to reducing avoidable referrals. Scotland and Wales have led the way in developing national schemes to ensure that more care takes place in the community and fewer avoidable referrals take place.   

We call on Integrated Care Systems in England and their constituent CCGs to commission services as defined by the Clinical Council for Eye Health Commissioning Primary Eye Care Framework for first contact carev, from primary care optical practices including: 

  • Minor Eye Conditions (MECs)
  • Integrated Cataract Care (Pre and Post Op)
  • Glaucoma Referral Filtering and Monitoring (as outlined in NICE Glaucoma Guidance NG81)vi 

Commissioners and national NHS bodies should also support the development of IT links between hospitals and community optometry so that quality structured referrals can be made quickly and securely, and feedback on and support for referral decision-making can be more easily provided. 

Ophthalmologists and optometrists:

Individual ophthalmologists and optometrists can contribute to improving referrals through communication and collaboration:

  • Develop and work to joint local care guidelines and referral criteria within the context of national pathway and guidance recommendationsvii  including The College of Optometrists guidance and advice servicesviii   
  • Build relationships between local primary and secondary care, including optometrist visits to the hospital eye clinic where possible
  • Implement good practice identified in national studiesix  such as combining active local education and good referral practice


  • Provide clinical feedback to all referring practitioners
  • Be actively involved in education and development of local optometrists as primary eye care providers 


  • Send clear, concise and legible structured referrals which contain sufficient information to enable safe triage, including a timescale within which it is recommended the patient is seen
  • Take care not to give patients unrealistic expectations of how quickly they will be seen   
  • Use feedback received from the local Hospital Eye Services (HES) for improving future referrals

Hospital Eye Services 

Although HES are operating under great pressure, executives, managers and clinical leads with responsibility for HES can work with primary care optometrists to facilitate appropriate referrals:

  • Promote ophthalmologists and optometrists working together to establish referral guidelines, supported by opportunities for education for primary care optometrists including shadowing clinicsx  
  • Provide advice to primary care optometrists on their preferred format of structured referralxi 
  • Develop pathways to support referral decision making (telemedicine/support phone lines and advice and guidance)
  • Ensure feedback on referrals

We also recommend that employers:

  • Ensure optometrists are given time to discuss referrals with colleagues either in practice or virtually
  • Ensure optometrists are given appropriate time to write referrals and to review feedback received
  • Support optometrists to take up opportunities for development through CET provision and spending time at their local hospital
  • Ensure that there are easily accessible policies in place to advise all staff of local HES pathways


i All party parliamentary group (APPG) on eye health and visual impairment. See the light; improving capacity in NHS eye care in England. RNIB, June 2018.
ii Foot, B., MacEwen, C. Surveillance of sight loss due to delay in ophthalmic treatment or review: frequency, cause and outcome, Eye volume31, pages771–775 (2017) see also: https://www.rcophth.ac.uk/2017/02/bosu-report-shows-patients-coming-to-harm-due-to-delays-in-treatment-and-follow-up-appointments/
iii  Healthcare Safety Investigation Branch, Lack of Timely Monitoring of Patients with Glaucoma, January 2020
iv  McEwen, C. Davis, A. and Chang, L. GIRFT Report: Ophthalmology. December 2019. 
Clinical Council for Eye Health Commissioning, Primary Eye Care Framework for first contact care, 2016 revised 2018  
vi  National Institute for Health and Care Excellence Guideline NG81, Glaucoma: diagnosis and management, November 2017
vii  Available frameworks for commissioning include Clinical Council for Eye Health Commissioning tools and frameworks and LOCSU clinical pathways
viii  College of Optometrists: Clinical Advice Service and Guidance for Professional Practice 
ix  McEwen, C. Davis, A. and Chang, L. GIRFT Report: Ophthalmology. December 2019
x  Akbari, A. Mayhew, A. Al-Alawi, M. Grimshaw, J. Winkens, R. Glidewell, E. Pritchard, C. Thomas, R. Fraser, C. Interventions to improve outpatient referrals from primary care to secondary care (Review). Cochrane Database of Systematic Reviews 2008, Issue 4
xi  Davey, C.J., Scally, A.J., Green, C.,Mitchell, E.S., Elliott, D.B. Factors influencing accuracy of referral and the likelihood of false positive referral by optometrists in Bradford, United Kingdom. J.optom.2015.10.007

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