College responds to consultation on integrated care systems (ICSs)

1. Share examples from the health and care system, where local leaders and organisations have created transformational change to improve people’s lives.

Eye health providers and commissioners have worked together to improve access to primary eye care services for the benefit of patients by designing and delivering new service models, for example the Minor Eye Conditions Service (MECS) and the COVID-19 Urgent Eyecare Service (CUES).

MECS provides optometry-led assessment and treatment for people with recently occurring minor eye problems without the need for a GP appointment or GP referral.

During the COVID-19 pandemic, primary care optometrists played a key role in maintaining access to eye care services for local populations and reducing pressures on the rest of primary care (such as GP practices) and ophthalmology departments within secondary care. CUES was created to offer diagnosis and treatment for patients with urgent eye conditions without the need for a GP referral by utilising all clinical skills of primary care optometrists to treat and manage eye conditions closer to home and making use of existing and new technologies to reduce patient–practitioner contact time.

During the pandemic, NHS England and optical sector bodies developed a first contact practitioner model called ‘Optometry First’ with the aim of reducing pressure on secondary care services and providing more care closer to home. Optometry First has been adopted by three ICSs so far, with the view to national roll out after evaluation of the early adopters. 

We have a unique opportunity to build on these achievements to reduce the backlog of patients in hospitals, and build a cost-effective, clinically safe and sustainable eye care service in England.

2. Do you have examples where policy frameworks, policies and support mechanisms have enabled local leaders and, in particular, ICSs to achieve their goals?

The College of Optometrists welcomes the intent of the ‘Triple Aim’ to ensure greater collaboration and decision making to help ICSs achieve their objectives of greater integration, more emphasis on preventative care and better utilisation of primary care. This should enable providers to manage patient care more collectively and efficiently.  We expect this will address health inequalities and unwarranted variation in the delivery of healthcare. It will improve joint working with public health services, giving opportunities for primary care professionals such as optometrists to provide more joined-up services for patients, or to signpost into other types of services, such as smoking cessation or weight loss and alcohol services. It will also improve joint working with social care, including mental health services, which are crucial for people experiencing sight loss.

Furthermore, the Government, advised by the DHSC and NHS England, and Parliament through the Health and Social Care Act 2022, has rightly maintained national contracting and standards for all core primary care services under the new structures. This is the most cost-effective route to reduce unwarranted variation, ensure consistent standards and equality of access.  This also provides strong foundations (which patients understand and value) which ICSs can build on to deliver ICS goals and locally commissioned enhanced services. This will help deliver more care closer to home and transform overstretched outpatient services. 

3. Do you have examples where policy frameworks, policies, and support mechanisms that made it difficult for local leaders and, in particular, ICSs to achieve their goals?

Not applicable.

4. What do you think would be needed for ICSs and the organisations and partnerships within them to increase innovation and go further and faster in pursuing their goals?

One of the main barriers to innovation in eye care is the lack of IT connectivity between primary eye care and the rest of the NHS, particularly hospital eye services and GPs.  In many ICSs, there are limited systems in place to enable effective electronic referrals, follow up letters to optometrists or even NHS emails.

IT connectivity is a key enabler for eye care transformation at all levels, such as shared care, enhanced primary care-based services, advice and guidance and shared decision-making.   It has the potential to prevent unnecessary patient visits to hospital and reduce avoidable sight loss and its associate costs.  It is a national problem, with both national and local solutions required.

However, IT connectivity requires careful implementation to ensure safe and effective deployment. To deliver this, primary and secondary eye care providers need to work with NHS England, and national optical bodies, to find a solution that works within and across geographical boundaries. The College of Optometrists and other bodies are supporting NHS England to develop solutions, which should be tested, funded and then rolled out promptly. 

5. What policy frameworks, regulations or support mechanisms do you think could best support the active involvement of partners in integrated care systems? 

We welcome Rt Hon Patricia Hewitt’s recognition of the need to mitigate the risk that ICSs become “a rebadged CCG or another layer of regulation and performance management.”

As the Fuller review recognised, a major delivery challenge for ICBs is how actively to engage primary care in strategic service planning and management through Integrated Care Partnerships (ICPs).  It is vital that ICB membership involves and represents the full range of primary care professionals, including optometrists. The care that primary care optometrists provide is and will be a core part of NHS service provision in every ICS area. There should be minimum national standards to ensure representation across primary care, not solely from GPs, with additional local flexibility to allow systems to fine-tune their governance arrangements.

Having optometric representation would ensure all patients’ needs are considered. It would ensure eye health is effectively included in general health decisions and would improve opportunities for more integrated and mutually supportive service provision. It would also ensure the entire workforce is taken into account and that decision-makers understand what eye care professionals can deliver to patients, and how the primary eye care workforce can increase capacity across systems.

Primary care optometrists should be involved in place-based initiatives in order to create real transformation, reduce pressure on the secondary care, deliver robust and sustainable care for all, and avoid missed opportunities and the difficulties that affected Clinical Commissioning Groups.

6. What recommendations would you give national bodies setting national targets or priorities in identifying which issues to include and which to leave to local or system level decision-making?

The recent Government ‘Plan for Patients’ is an important policy document that ICSs should use to measure impact, reduce variation of care and demonstrate better patient outcomes through better partnership working. It is important to ensure the plan’s aims are part of local priorities and target setting.

ICSs should prioritise embedding clinical pathways and services that are already known to work, rather than develop more pilot or proof of concept initiatives. The eye care examples mentioned in our response to question 1 (MECS and CUES) have already been successfully tested and locally implemented in many areas. ICSs should build on these achievements and learning, and introduce new services such as Optometry First. This would reduce the backlog of patients in secondary care and build a cost-effective, clinically safe and sustainable eye care service that effectively uses the primary eye care workforce.

We recommend ICSs to prioritise the digital transformation of eye care, to ensure a better use of the primary care workforce, and to prevent avoidable sight loss.

7. What mechanisms outside of national targets could be used to support performance improvement?

As many reviews of the NHS have shown, there is a need to improve dissemination of best practice and information on models that work effectively across ICSs. One barrier is that individuals responsible for a particular service in one region cannot easily contact a person in another region who has already successfully implemented change.

The FutureNHS Platform is an example of a tool that might help tackle this. Networks and Communities of Practice could also be set up to facilitate information sharing and learning.  

8. Do you have any examples, at a neighbourhood, place or system level, of innovative uses of data or digital services?

Digital connectivity
Currently, primary eye care services are not universally digitally connected to secondary care services. For example, in many places this means that optometrists cannot easily make digital referrals, sometimes having to go through a GP to do so. This continues to cause issues for patient outcomes and also for efficiency of the system through unnecessary clinical and administrative burden.

Lack of connectivity can lead to delayed diagnosis, unnecessary referral and lack of up-to-date patient records when the patient returns to primary care. It is one of the main barriers to addressing the long-standing issue of ophthalmology backlogs and the delivery of outpatient transformation as it hinders the safe transfer of care between professionals. 

New e-referral systems are being developed. We hope NHS England will soon develop a solution which can be funded and rolled out at scale to benefit patients, the NHS and taxpayer. 

Data
The RightCare data toolkits and Atlas of Variation are good examples of innovative use of data which could be used more to seek out system improvements.

The College of Optometrists - together with 16 other organisations from across the whole of the eye care sector - are collaborating on a sector-wide and UK-wide, multi-professional eye care workforce supply and demand data modelling project. The main project output is to collate available data and develop a projection of the current primary and secondary eye care workforce in each nation of the UK, filling the gaps in primary care workforce knowledge. A data-driven, multi-professional approach to understanding eye care workforce supply and demand will help informing decision-making and interventions to ensure adequate eye care provision for service users across the UK, now and in the future. We are looking at creating a user-friendly, interactive dashboard with all the data collected. The dashboard should enable healthcare commissioners, health professionals and the eye care sector to understand current and future workforce trends and patient needs for any given defined local authority and identify where changes are required in service delivery and workforce development and deployment. Systems should be able to access a single data platform, rather than developing new datasets that replicate or overlap with data that already exists.

9. How could the collection of data from ICSs, including ICBs and partner organisations, such as trusts, be streamlined and what collections and standards should be set nationally?

There is an urgent need to improve and streamline the process for the collection and sharing of data within NHS systems. There is currently no shared understanding or consistency of the data that is collected, which metrics are useful and how data is used for performance monitoring, evaluation and research.

We would support a set of principles that outline meaningful and proportionate reporting requirements, avoid duplication in reporting and allow meaningful comparison between ICSs. We recommend that ICSs establish appropriate and proportional data collection using a set of agreed and predefined measures and metrics that allow meaningful comparison between ICSs. This would improve how success and impact could be accurately measured and benchmarked. 

Within eye care, there should be proactive collection of data on activity, clinical outcomes, quality of care and cost effectiveness across every ICS system which is shared with healthcare professionals, funders, regional and national NHS bodies. Clinical audit and performance measures should be agreed between optometric and ophthalmic leads and any other regional or transformation leads. Reporting, and utilisation of the data should lead to learning with rapid improvement actions, particularly for new services. Suggested measures can be found in The College of Optometrists and Royal College of Ophthalmologists Joint statement on our vision for safe and sustainable patient eye care services. 

10. What standards and support should be provided by national bodies to support effective data use and digital services?

Better quality data across eye care pathways is essential. Commissioners cannot make strategic decisions on eye care or properly understand its importance when they have too little data. This crucial evidence will help commissioners understand local demand for eye care and identify any unmet need. Without high quality data, developing innovative approaches to preventing sight loss will be severely hampered.

We need to have an accurate understanding of the population’s needs in order to plan effective and appropriate eye care services. As a first step, the existing data in the General Ophthalmic Services payments systems and hospital clinical systems needs to be collated and used to best inform ICS planning and commissioning. We would then like to see a move towards better quality and more comprehensive data collection at ICS level, which can be used to inform both local and national primary care service provision. 

We recommend the following principles:

• To collect only meaningful data and avoid duplication of reporting requirements 
• To collect data that allows for meaningful local, regional and national comparison
• To collect data that does not add extra burden to providers or clinicians
• To use data to foster service improvement, learning and collaboration. This is more likely to improve patient outcomes and NHS efficiency in the long run.
• To develop a plan for utilising data more widely, e.g. for academic research.
• To ensure that digital services and technologies are standardised to ensure connectivity and interoperability, eg DICOM.

11. What do think are the most important things for NHS England, the CQC and DHSC to monitor, to allow them to identify performance or capability issues and variation within an ICS that require support?

We acknowledge that ICSs are still relatively new and in the process of establishing their priorities and processes. However, we think that the following key indicators should be monitored:

• Waiting list datasets 
• Patient reported outcomes and experience measures
• Impact on population health inequalities 
• Rate of first and follow up outpatient attendances and admissions per 100,000 population
• Certification of Visual Impairment metrics and access to support such as ECLOs
• Eye care activity commissioned in primary care
• Use of optometrists as First Contact Practitioners 
• Referral data related to referral refinement activities, the number of patients referred to hospital eye services, the number of patients referred to extended services provided in primary care, the number of patients fully managed within primary care. 

12. What type of support, regulation and intervention do you think would be most appropriate for ICSs or other organisations that are experiencing performance or capability issues?

Not applicable.

13. Is there any additional evidence you would like the review to consider?

ICSs must transform outpatient and hospital eye care to achieve better outcomes and a more sustainable system. The focus should be on equitable and sustainable access for all patients, making full use of the skilled eye healthcare professional workforce, particularly optometrists.

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. Our vision is for eye care pathways that ensure patients are prioritised based on their clinical need and receive care that is appropriate and accessible. Multidisciplinary professionals should provide that care, working collaboratively in primary care, community and hospital settings. 

There is also an urgent need to understand eye care workforce requirements now and in the future, in order to meet patient need and improve 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. However, there is a lack of up-to-date data on both current population need and granular workforce capacity.

The College of Optometrists has developed a vision for the optometry workforce that is fit for the future. We are working with partners to commission an analysis of current and future population need, and the development of a workforce data model, to fully understand eye care workforce supply and demand.