1 April 2022

Our response to the Academy of Medical Royal Colleges' consultation on OCT use

The consultation covered OCT use in diabetic retinopathy referral, shared decision making for cataract surgery, and glaucoma referral criteria.

Summary

The College has responded to the Academy of Medical Royal Colleges' consultation on OCT use in diabetic retinopathy referral, shared decision making for cataract surgery, and glaucoma referral criteria. We have made recommendations to ensure that any changes to guidance will benefit all patient groups, and will maximise the full skills and competencies of optometrists; as well as calling for appropriately funded and commissioned services.

Our response

Q1. Optical coherence tomography (OCT) use in diabetic retinopathy referral

Q1a. Do you agree with the proposed clinical guidance?

Yes.

Q1b. Do you think that the EBI programme’s proposal will have a positive or negative impact on the access experience or outcomes of groups protected under the Equality Act 2010?

Not sure.

Although these proposals are likely to benefit all patients requiring diabetic retinopathy referral, there are certain patient-groups who are at higher risk of diabetes such as people of South Asian, African and African-Caribbean origin, as well as those living in areas of higher rates of deprivation. In addition to the increased risk of diabetes, evidence suggests that patients from these groups are less likely to have their diabetes under control1. See below for further details.

Q1c. Do you think that the EBI programme’s proposal will have a positive or negative impact on the access experience or outcomes of those individuals who experience health inequalities, such as people who are homeless or insecurely housed, former prisoners, gypsy, Roma, traveller, veterans and carers?

Not sure.

As above, patients in areas of higher rates of deprivation suffer a greater risk of diabetes, and are less likely to have their diabetes under control1; and so it would be anticipated that there would be a corresponding higher risk of diabetic retinopathy and visual impairment. In addition, patients from these groups may not have equal access to primary eye care services, either through problems accessing care or through low uptake of services2

Q1d. Do you have any additional comments on this intervention?

Although the proposals are welcome, we believe that in order for their success to be maximised across all patient groups, primary care optometrists and optometry practices need to be better utilised and funded to provide OCT diagnostic imaging and referral.

Although many optometry practices have OCT, in some areas of deprivation OCT is not available as practices don’t have the funds to invest in the technology. In addition, it is possible that in some areas, there are not enough primary care optometrists with higher qualifications in medical retina to provide these services.

An additional concern is that of digital connectivity to link services and imaging file compatibility (including lack of universal image sharing standards such as DICOM). The use of OCT is often restricted by the use of multiple devices and storage processes across care providers that reduce interoperability, and limitations on the ability to share data. It is important that the primary eye care sector works with manufacturers to address some of these immediate concerns, as well as some of the longer term challenges that will develop in future, as hardware and software outdates.

It should be noted that retinal screening for the complications of diabetes is part of the National Diabetic Eye Screening Programme, and not part of the GOS sight test. In order for optometrists to be able to provide a service to patients (and use their skills and competencies to the top of their license), these services must be commissioned – and commissioned universally across the UK – to avoid a postcode lottery, and in particular to ensure all community groups have equal access. 

We recommend that the proposals be considered in conjunction with the National Diabetic Eye Screening Programme expert advisory group - which is now part of NHS England/Improvement.

Q2. Shared decision making for cataract surgery

Q2a. Do you agree with the proposed clinical guidance?

Yes.

Q2b. Do you think that the EBI programme’s proposal will have a positive or negative impact on the access experience or outcomes of groups protected under the Equality Act 2010?

Not sure.

Although these proposals may benefit all cataract patients, including those from groups protected specifically under the Equality Act 2010, there may be patients from areas of higher deprivation where the benefits may not be fully realised (see below).

Q2c. Do you think that the EBI programme’s proposal will have a positive or negative impact on the access experience or outcomes of those individuals who experience health inequalities, such as people who are homeless or insecurely housed, former prisoners, gypsy, Roma, traveller, veterans and carers?

Not sure.

Patients from areas with higher levels of social deprivation often present to primary care optometrists with poorer vision and more severe cataract than those from less deprived areas; and so their visual outcomes are often worse3. Shared decision making is welcome across all patient groups, but as these specific groups often present late in their disease, there may not always be the full range of options available. Patients must have appropriate resources and support to make an informed decision, so it is vital that patients from these groups have access to information and resources that are tailored to their specific needs. 

Q2d. Do you have any additional comments on this intervention?

Primary care optometrists identify cataracts during routine sight tests (both NHS and private), and have the capability to assess cataract severity, and its impact on visual acuity and quality of life. Where commissioned, they provide patients with information on treatment options, impact on quality of life, counselling about what surgery involves (including risks and benefits) and obtain consent for referral to secondary care. A barrier to this happening more widely is local commissioning arrangements. To enable sufficient time for an optometrist to support this decision-making process, a local service needs to commission a suitable pathway to provide the resources for a formally documented shared decision-making process which can be included as a supplement to the referral. 

There are examples of best practice where this happens well, and ICS’s should be supported to ensure all service users have access to a meaningful decision making process, access to high quality supporting resources to enable a robust patient choice decision, and sufficient information to grant consent to proceed with the initial cataract referral. 

Patients should also be allowed time for reflection, and discussion with friends and family if preferred, before making a decision, to be sure it is fully informed. A follow up virtual appointment with the patient should be accommodated within the commissioned patient pathway. 

The College of Optometrists, The Royal College of Ophthalmologists and the Clinical Council for Eye Health Commissioning should be consulted in the development of a cataract care pathway. As part of this, service users should be central to informing pathway development.
 

Q3. Glaucoma referral criteria

Q3a. Do you agree with the proposed clinical guidance?

No – see under additional comments.

Q3b. Do you think that the EBI programme’s proposal will have a positive or negative impact on the access experience or outcomes of groups protected under the Equality Act 2010?

Not sure.

Although these proposals may benefit all glaucoma patients, including those from groups protected specifically under the Equality Act 2010, there may be patients from minority ethnic communities who are at higher risk of glaucoma4 and/or who may not present to primary care optometry, or do so late in their disease.

Q3c. Do you think that the EBI programme’s proposal will have a positive or negative impact on the access experience or outcomes of those individuals who experience health inequalities, such as people who are homeless or insecurely housed, former prisoners, gypsy, Roma, traveller, veterans and carers?

Not sure.

The College would support targeted glaucoma screening for at-risk groups of adults over 40, beyond the current family history category. This would help identify the 50% of undiagnosed people affected by primary open angle glaucoma5; particularly in higher risk groups who are less likely to take up a routine sight test6 – this would help to reduce health inequalities.

Q3d. Do you have any additional comments on this intervention?

We recommend the removal of the Glauc-Strat-Fast (GSF) tool from the referral criteria, as it is not a tool for the purpose of supporting glaucoma referral but is for risk stratifying patients once diagnosed with glaucoma. 
 

Primary care optometrists have the capability, skills and competencies to provide more care for people with glaucoma and ocular hypertension in the community, and so avoid unnecessary hospital appointments. Glaucoma services are not within the scope of the GOS funded sight test, and the primary barrier to improved patient experience is the lack of suitably commissioned glaucoma pathway services in England. The College of Optometrists and The Royal College of Ophthalmologists have produced joint commissioning guidance7 which should be considered, as should input and guidance from the Clinical Council for Eye Health Commissioning. Service users’ needs should be considered first and foremost and they should be central to informing pathway development.

The language in the recommendations should be aligned to that used within the NICE NG81 Glaucoma: Diagnosis and management guidelines, using the same definitions for repeat pressures, enhanced case finding and referral refinement. 

Additional comments (applicable to all criteria)

  1. The term ‘optometrist’ should be used throughout this criteria, rather than optician.
    • Optometrists examine the eyes to detect defects in vision, signs of injury, ocular diseases or abnormality. They prescribe glasses or contact lenses, and diagnose and manage patients with certain eye conditions. Optometrists can also identify the signs of problems with general health, such as diabetes or high blood pressure. Optometrists with higher qualifications manage and treat a wider range of eye conditions, both in primary and secondary care.
    • Dispensing opticians advise on and fit glasses according to a prescription provided by an optometrist or ophthalmologist. They offer advice on lenses for specific purposes, such as night driving, UV protection or sports and safety wear.

2. The College of Optometrists’ report ‘See the gap’ summarises the evidence around inequalities associated with patient access in deprived areas. 

A collaborative approach to integrated eye care

The College of Optometrists and The Royal College of Ophthalmologists have developed a joint vision to support our workforce and the commissioning of safe and sustainable eye care services that meet the needs of all patients, improving patient care and outcomes during and beyond the pandemic. A collaborative approach to integrated eye care between optometry and ophthalmology is necessary to ensure patients are prioritised based on their clinical need, and receive care that is appropriate and accessible. We believe that: 

  • For patients already in the hospital eye service (HES): Ophthalmology leads in the HES should continue to use risk stratification (into low/medium/high risk of harm) and clinical prioritisation of all patients to decide on ongoing management most suitable to their needs. Whilst there is a return to more face to face care with appropriate precautions, many patients will benefit from remote (telephone or video) and virtual diagnostic appointments provided by the hospital and in the community. Systems should be developed to take advantage of the expertise and facilities in primary care to allow patients to be managed in primary care optometry, with HES input as required. 
  • For new non-urgent referrals: Utilisation of recognised pathways should be put in place for referral filtering and refinement by primary care optometrists, including advice and guidance for primary care optometrists and GPs, with accessible support from the HES.  
  • For urgent and emergency referrals: Hospitals should provide accessible timely triage for urgent referrals and advice and guidance for primary care optometrists and GPs.  
  • For all outpatients: Continued use of primary care optometry services to see patients who have conditions that can be diagnosed and/or treated within primary care, in conjunction with hospital-based referral and support from an appropriate clinician as required.  

Managing patients in this way will help to support and facilitate the development of primary care and community services with close links to the HES. This will enable all patients to have equitable access to the eye care that they need at the time it is needed and avoid unnecessary visits to the HES.  

References

  1. Katharine D Barnard-Kelly, Social Inequality and Diabetes: A Commentary, Diabetes Ther (2020). Available at: https://pubmed.ncbi.nlm.nih.gov/32124269/
  2. D. Shickle, Geographical inequalities in uptake of NHS-funded eye examinations: small area analysis of Leeds, UK, Journal of Public Health, Volume 37, Issue 2, June 2015, Pages 337–345. Available at: https://academic.oup.com/jpubhealth/article/37/2/337/1591677
  3. Alexander Silvester, Impact of social deprivation on cataract presentation and surgical outcome in the north of England: a retrospective cohort study, The Lancet, VOLUME 392, SPECIAL ISSUE, S81, NOVEMBER 01, 2018. Available at: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32921-0/fulltext#%20
  4. Mark O. Scase Visual impairment in ethnic minorities in the UK, International Congress Series 1282:438-442. Available at: https://www.researchgate.net/publication/223903501_Visual_impairment_in_ethnic_minorities_in_the_UK#pf5
  5. Mitchell P, Smith W, Attebo K, Healey PR. Prevalence of open-angle glaucoma in Australia. The Blue Mountains Eye Study. Ophthalmology. 1996 Oct;103(10):1661-9. doi: 10.1016/s0161-6420(96)30449-1. PMID: 8874440.
  6. Day F, Buchan JC, Cassells-Brown A, Fear J, Dixon R, Wood F. A glaucoma equity profile: correlating disease distribution with service provision and uptake in a population in Northern England, UK. Eye (Lond). 2010 Sep;24(9):1478-85. 
  7. The Royal College of Ophthalmologists/The College of Optometrists. Commissioning better eye care: glaucoma. 2013; version 2

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