College calls for greater investment in the optometry workforce

Optometrists are health professionals who are qualified 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. They make a health assessment, offer clinical advice and treatment recommendations, prescribe spectacles or contact lenses and refer patients for further treatment, when necessary.

In addition they may also treat a range of eye conditions, and can manage and provide care for cataract patients (pre and post treatment) as well as managing conditions such as glaucoma in the community. Some also have further qualifications enabling them to prescribe medicines for eye conditions where appropriate, and provide an advanced level of eye care. They work across both primary and secondary care, as well as in community and domiciliary settings, and in academia and research.

There are approximately 13,000 optometrists registered in England, with around 10,000 working in primary care. Many optometrists will divide their clinical practice between primary and secondary care; and are a key part of the NHS workforce. Optometrists provide over 13 million NHS sight tests in primary and domiciliary settings each year.

Many optometrists will undertake further qualifications and develop their interests in specialist areas of practice such as independent prescribing. The College offers a range of higher qualification courses, developed and delivered by universities and hospitals, and accredited by The College of Optometrists. These include glaucoma, low vision, medical retina and paediatric eye care. However, due to a lack of appropriately funded and commissioned services, many optometrists are not able to use these additional skills and competences.

There is an obvious need to address not only the pre-existing backlog of patients, but also the additional backlog due to the pandemic and the predicted burden on the NHS in the future.

However, there is a lack of up-to-date data on both current population need (i.e. the prevalence of vision-threatening conditions at a system level in England) and granular workforce capacity across all professions of the eye health sector; and there is now an urgent need to understand eye care workforce requirements if the NHS is to meet patient need and improve eye health outcomes.

A data-driven, multi-professional approach to understanding eye care workforce supply and demand is needed to inform decision-making and interventions relating to workforce planning, investment, training, and deployment. The College of Optometrists is developing a vision for the optometry workforce that is fit for the future. We would like to work with partners, such as Health Education England, to commission an analysis of current and future population need, and the development of a workforce data model, to achieve a full understanding of the eye care workforce supply and demand across the UK.

In the meantime, optometrists are ready and well positioned to play a wider role in transforming eye health delivery alongside other health professionals. Realising this potential and therefore the full benefits for patients and for the health and care system, can usefully be achieved by ensuring that optometry is linked into broader workforce transformation agendas.

With the introduction of Integrated Care Systems in 2022, primary care optometrists should be involved locally in co-developing and leading the workforce planning required for effective care pathways. Where there are common development or training areas across primary care pathways (e.g. governance, audit, and service evaluation), it would make best sense for this training to be made available to all primary care professionals, including optometrists.

Furthermore, with new care pathways expected to be piloted and commissioned over the next few years - including enhanced care pathways - there will be a greater demand for optometrists with higher qualifications and independent prescribing. We will need to identify where there are advanced skills gaps in the workforce and proactively support optometrists with an interest in these areas to obtain the relevant higher qualifications.

As the UK emerges from the pandemic, it is more important than ever to develop more integrated eye care between all organisations across the hospital eye service, the independent sector, community settings and primary eye care. Eye care services need to incorporate innovative models to improve patient care and outcomes in a way that is sustainable and within the limited resources of the NHS.

NHS England/Improvement is leading a National Eye Care Recovery and Transformation (NECRT) Programme, which enables and supports all local systems in England to deliver radical transformation of outpatient eye care services across primary, secondary and community care. This work also supports the NHS Long Term Plan which recommends moving more care outside the hospital and back to the community. The College of Optometrists is directly involved with the NECRT programme, contributing to all areas of work.

The programme aims to reduce face-to-face outpatient attendances and drive the development of innovative, integrated, safe and sustainable ways of working. This is to both reduce the impact of the COVID-19 pandemic on already over-stretched hospital eye services and to better manage the diagnosis and care of increasing numbers of patients with eye conditions in the future.

New integrated eye care pathways covering cataract, glaucoma and medical retina will be a key part of the NECRT. As part of this, we would like to see more of the case finding, diagnosis and risk-stratified management transferred to primary and community eye care professionals, and shared care and decision-making in place across primary and secondary care.

Pathways and services should be integrated at geographies larger than single hospital level, where possible, and long-term improvement plans put in place; with a joint lead optometrist and lead ophthalmologist for the pathways. There should be equity of access to enhanced services developed on the basis of population need, rather than on a historical basis.

As part of the NECRT programme, the College and our partners in the optical sector would like to see an ‘Optometry First’ scheme established. Optometry First is a first contact provider service commissioning and design principle to help manage growing demand in a sustainable way, reducing pressure on the hospital eye service (HES) and benefiting patients and the wider NHS.

The fundamental shift at the heart of Optometry First would be that many patients with eye conditions can be appropriately managed within primary care optometry and only referred to the hospital eye service if clinically necessary. This includes patients who are currently on regular follow-up plans within hospital, but who can be transferred to a service closer to home. 

If rolled out nationally, Optometry First would help achieve transformation through care closer to home, and the best use of the existing 13,000 optometrists, 5,700 dispensing opticians and their teams in primary care. It would also bring a wider range of services to patients in a coordinated way across communities.

Optometrists have already played a key role in supporting hospital ophthalmology and GP primary care teams in reducing existing burden and dealing with the backlog of patients.

In response to the pandemic, NHS England/Improvement (NHSE/I) regional teams worked with commissioners, health systems and primary eye care practices to ensure the availability of appropriate and adequate levels of urgent eye care commissioned and delivered through a contract with local commissioners. This was based on the COVID-19 Urgent Eyecare Service (CUES) – a service framework developed and endorsed by NHSE/I, The College of Optometrists, LOCSU, The Royal College of Ophthalmologists and the Clinical Council for Eye Health Commissioning.

Through a network of primary eye care practices, and better utilisation of technology, patients were able to gain prompt access to a remote consultation. Patients were able to:

• self-manage their eye condition (with access to appropriate topical medications where appropriate);
• be managed by their optometrist with advice, guidance and remote prescribing as necessary;
• be appropriately referred to hospital ophthalmology services.

The NHS must utilise the full core skills and competences of optometrists, both in primary and secondary care. Services must also be commissioned and funded which make full use of the higher and independent prescribing qualifications that many optometrists hold, which in many cases are not being deployed to their full potential.

The COVID-19 crisis has showcased the role of primary care optometrists as ‘first contact’ healthcare providers for eye health, and accelerated the role of advanced optometric practice via College higher qualifications and training. We have a unique opportunity to build on these achievements to address the backlog and build a cost-effective, clinically safe and sustainable eye care service.

Primary care optometrists are well-placed to provide enhanced and shared eye care services closer to home, and to reduce the backlog of delayed outpatient appointments through both referral refinement and autonomous management of certain eye conditions, without additional training. 

Optometrists can play an essential role in taking the pressure off hospital eye care services, and make a significant contribution to reducing avoidable sight loss by:

• safely delivering urgent eye care in the community;
• making use of higher qualifications, skills and competences to treat and manage eye conditions in the community;
• making use of existing and new technologies to reduce patient–practitioner contact time;
• reducing the burden on the rest of primary care (such as GP practices) and reducing pressures on ophthalmology departments within secondary care;
• maintaining local access to quality eye care services for local populations.

The NHS must build on these skills and ensure that appropriate funding is made available now and in the medium and longer term to ensure that there is adequate investment in training, recruitment and development of optometrists to meet demand.