College response to inquiry into Ophthalmology Services in Wales

1.1. The College of Optometrists would like to thank the Health and Social Care Committee for the opportunity to contribute our views to this important inquiry into Ophthalmology Services in Wales.

1.2. The new ophthalmic services regulations, that took effect in October 2023, have significantly transformed the delivery of primary eye care services for the benefit of every Welsh citizen. The reforms will improve patients’ access to eye health services, ensuring that support is delivered by the right professional in the right place.

1.3. Optometrists are an integral part of the transformation of primary eye care services¹. The new regulations utilise their full professional capability by rightly expanding the core eye care services provided in primary care to reduce the number of referrals into hospital eye services (HES).

1.4. However, we acknowledge that at the end of January 2025 there were around 81,000 people² in Wales still waiting beyond their target date for an ophthalmology appointment, putting them at the highest risk of irreversible sight loss, and over 160,000 patients waiting for an ophthalmology appointment.

1.5. While reforming primary eye care is a crucial step to improve patients’ access to eye health services, it is not the sole solution; significant investment and reform in secondary eye care are still necessary to improve patient outcomes and address the growing demand.

1.6. The implementation of the new Wales General Ophthalmic Services (WGOS) has created a positive cultural change within optometry and primary eye health, and The College of Optometrists is ready to continue to work with the Government, NHS Wales and Health Boards to help tackle sight loss due to delays in accessing overburdened secondary eye care services.

2.1. The College of Optometrists is the professional body for optometry. It qualifies the profession and delivers the guidance and training to ensure optometrists provide the best possible care. We promote excellence through the College’s affixes, by building the evidence base for optometry, and raising awareness of the profession with the public, commissioners, and health care professionals.

2.2. Further information can be found on the College website.

3.1. The recent Optometry Contract Reform under Wales General Ophthalmic Services (WGOS) has led to radical and groundbreaking change, further integrating primary and community care optometrists into the eye care service model and allowing optometrists to work to the top of their skillset in primary care.

3.2. The Welsh Government has long worked towards the integration of primary and community optometrists and the hospital eye service by shifting a growing number of eye care services from hospital to primary care optometry:

• in 2003, the Primary Eyecare Assessment and Referral service (PEARS) was introduced and allowed accredited optometrists to assess and refer patients with minor eye conditions directly to specialist services, which resulted in reducing the burden on GPs and secondary care¹.
• in 2004, the Low Vision Service Wales (LVSW) was introduced and had entirely replaced all secondary care-based low vision services in Wales. LVSW offered an extended (60-minute plus) appointment with an accredited optometrists who could then prescribe various low vision aids loaned to the patient free of charge².
• in 2013, the Eye Health Examination Wales Service (EHEW) – replacing PEARS and Wales Eye Health Examination (WEHE) – was introduced, enabling accredited optometrists to assess and refer patients with urgent eye problems or at risk of eye disease.

3.3. Following legislative changes in 2023, Wales General Ophthalmic Services (WGOS), consisting of five levels of service[3], replaced General Ophthalmic Services (Wales), Eye Health Examination Wales, Low Vision Services Wales, and many various local enhanced service pathways.

3.4. Optometry practices across Wales have fully embraced the change and the move to a more clinical focus with many clinicians undertaking additional training to upskill in the required qualifications:

• WGOS 1: As of 31 March 2024, 317 optometry practices were providing WGOS 1 services, with a further 42 exclusively providing WGOS mobile services^[4]. In 2023-24 the number of sight tests paid for by the NHS increased to a record high of just over 841,000; an increase of 6.6% compared to 2022-23⁶.
• WGOS 2: There were over 243,000 total examinations claimed for under WGOS 2 in 2023-24, an increase of 15.8% from similar services offered through EHEW in 2022-23⁶.
• WGOS 3: 8,400 low vision assessments were carried out in 2023-24, an increase of 3.7% since 2022-23. 87.2% were initial assessments, and the remaining 12.8% were follow-ups⁶.
• WGOS 4 is currently being rolled out across Wales. The Health Boards that previously had local services prior to contract reform have been faster to implement the new services, but all seven Health Boards have now commenced at least one of the patient pathways.
• WGOS 5 has been very recently implemented, and we expect a significant and growing number of patients being seen in primary eye care that would traditionally have been seen in hospital Eye Casualty clinics as more optometrists are qualifying as independent prescribers in Wales⁷.

4.1. A sustainable future for eye care can only be achieved by investing dedicated time and resources into the training of the next generation of the optical workforce.

4.2. As part of our Workforce Vision, The College of Optometrists and its stakeholders, including the Welsh Government, have developed a UK Eye Care Data Hub to estimate the current eye care workforce and eye disease prevalence or incidence, and to model future trends over time. It has been designed to support commissioners and designers of eye care services to identify future population eye care needs and optimise the existing eye care workforce. This knowledge should help commissioners better meet eye health needs, identify priorities for future workforce education, training and development, and support the development of new models of care.

4.3. In addition, as part of 2023 Optometry Contract Reform, the Welsh Government has introduced a Quality for Optometry mandatory contract requirement for all optometry practices. From January 2025, all optometry practices are required to submit monthly workforce data which includes skillsets and higher qualifications. This data will help identify any workforce shortages to then support targeted interventions for a particular qualification or in a specific geographic area.

4.4. The College of Optometrists offers range of higher qualifications in Independent Prescribing, Glaucoma, Medical Retina and Low Vision to enable optometrists in Wales to extend their areas of care.

4.5. The Welsh Government have been very supportive in upskilling optometrists through funding provided to Health Education and Improvement Wales (HEIW) to qualify practitioners in Independent Prescribing, Glaucoma, Medical Retina and Low Vision. They have also supported the establishment of three Teach and Treat Eye Care Centres in North, West and South Wales. These Centres help reduce hospital waiting times for patients requiring eye care, while providing in a clinical environment the skills required for optometrists in Wales to deliver a greater range of eye care services in primary care settings. This ensures that clinical placements required for many of the higher qualifications can be accessed by all practitioners in a timely manner.

4.6. In addition, the Welsh Government have supported HEIW to establish Advanced Training Practices which fund appropriately skilled optometrists to host a clinical placement within their own practice to further enhance placement capacity. This initiative funds practices who release practitioners to complete glaucoma clinical placements for time taken out of practice.

4.7. Finally, the Welsh Government is supporting optometrists for their continuing professional development, with higher fees associated with gaining higher qualifications and providing WGOS 3, 4 and 5 pathways.

4.8. The College of Optometrists welcomed the additional £3.9m funding for optometry services in Wales announced by the Welsh Government in February 2025. We are pleased to see optometry being championed in Wales with this uplift in funding for primary eye care services and optometry training that will help reduce the hospital waiting times for patients and improve access to specialist care.

5.1. Digital/IT connectivity is a key enabler to transform eye care service delivery. Primary eye care has already embraced technology and invested in advanced digital assessment and diagnosis tools, such as OCT. We expect further significant technological changes in the next decades, which could transform the role of the optometrists and improve patients’ outcomes. The most significant will be the use of artificial intelligence (AI) to diagnose eye disease.

5.2. Good patient care requires effective communication between and within primary, community and secondary care to support improved patient experience and outcomes, for example to enable effective referrals and shared care provision.  A major barrier to achieving this is a lack of an effective digital solution for eye care in Wales that continues to limit the transformation of services and the potential of WGOS reforms.

5.3. Many optometrists cannot access electronic patient records (EPR) and cannot digitally refer to their local hospital eye service. This prevents optometrists and ophthalmologists from working better together and improving patient outcomes from simple improvements such as referral feedback through to shared management of patients. Many digital images (including OCT scans) cannot be shared between optical practices and the hospital, meaning that patients must have the same images taken again at the hospital after referral. This lengthens delays in diagnosis and treatment and increases unnecessary costs for the NHS in Wales.

5.4. There is an urgent need to accelerate the implementation of digital systems like the ophthalmic EPR and eye care referral systems to ensure timely, secure and effective communication to improve patient care, and facilitate feedback between multidisciplinary professionals to aid learning and improve clinical decision making.

5.5. There is also the need for ensuring digital clinical image interoperability. Currently, there are several digital systems available to take and review ophthalmic clinical images within hospital trusts and optical practices. However, the historical lack of agreed interoperability standards means most of these systems and image files are incompatible with one another.

5.6. The College of Optometrists and the Royal College of Ophthalmologists are co-leading a digital imaging Task and Finish group which brings together healthcare professionals, the manufacturing industry and sector stakeholders to develop a set of Digital Imaging and Communications in Medicine (DICOM)⁸ standards that will drive interoperability of digital ophthalmic imaging systems. The adoption of digital image sharing standards by Health Boards and trusts, healthcare professionals and primary care practice owners will support better image sharing. This will ensure more efficient patient referrals and reduce delays in diagnosis and treatment. Investment may be needed to upgrade systems if existing equipment cannot meet DICOM standards.

6.1. Good quality data across eye care pathways is essential to improve patient access and experiences. Data helps commissioners understand local demand for eye care and identify any unmet need. Without high quality data, developing innovative approaches to preventing sight loss is also severely hampered.

6.2. We need to have an accurate understanding of a population’s needs in order to plan effective and appropriate eye care services. The existing Ophthalmology Clinical Implementation Network (CIN) brings together all stakeholders including third-sector organisations to discuss and agree ways to ensure equal access to care across regions, addressing disparities in care delivery and waiting time performance. Eye Care Collaborative Groups (ECCGs) established in each of the Health Boards with both primary and secondary care representation will help ensure an effective sharing of information.

6.3. Furthermore, Health Boards report progress of optometry contract reform implementation via a national reporting template and share best practice. This common sharing of WGOS data, alongside ophthalmology waiting time data, help assessing the effectiveness of new care pathways. NHS Wales Shared Services Partnership has committed to the introduction of a national dashboard to share this data with key stakeholders.

6.4. As already mentioned in paragraph 4.2 above, there is also an urgent need to understand eye care workforce requirements now and in future, in order to meet patient need and improve outcomes. Our UK Eye Care Data Hub models the expected changes in the workforce of all eye care professions at a national and Health Board level in Wales. This indicates the expected changes in workforce if no changes are made to education and training provision or to working practices. For example, the optometric workforce is expected to increase by 40% between 2025 and 2035, whereas ophthalmic nurses are predicted to decrease by 30%. This model should help commissioners make best use of the existing workforce and identify where to invest to ensure ophthalmic professions are maintained.

6.5. The College of Optometrists has directly contributed to and supported the development of the RNIB-led Eye Care Support Pathway that will, without doubt, result in improved care experiences for patients and their families, and improved outcomes. A cohesive, joined up approach right from the beginning, and throughout every patient’s journey, will further transform eye care at a time when eye care services have never been needed more.

7.1. As already mentioned in section 5 above, there is an urgent need to accelerate the implementation of digital systems like the ophthalmic EPR and eye care referral systems to ensure timely, secure and effective communication to improve patient care, and also facilitate feedback between multidisciplinary professionals to aid learning and improve clinical decision making.

7.2. The recent Optometry Contract Reform in Wales has significantly transformed the eye care service model that will enhance patient care. Key reforms have shifted many eye care services from hospitals to primary care settings, increasing the accessibility and volume of services. The Welsh Government has supported this transition with workforce training initiatives and funding, fostering the development of a highly skilled optometry workforce. However, challenges remain, particularly regarding digital infrastructure and data sharing, which are critical for streamlining patient care and ensuring equal access across regions. Continued investment in training, technology, and clinical networks will be essential to meet future demand and improve eye care outcomes in Wales.