Shaping the future of eye care service delivery

The NHS Five Year Forward View includes proposals around improved IT & communications, clinical leadership, eye care pathways, and a better use of skills.

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Author: David Parkins FCOptom
Date: 24 June 2015

Last week I spoke at the UK Vision Strategy conference on the NHS Five Year Forward View and what it means for eye care and the role of the optometrist. In developing the themes that were submitted to the Call to Action for eye health and sight loss in England, the Five Year Forward View includes proposals around improved IT & communications, the development of clinical leadership, more consistent eye care pathways, and a better use of skills. 

One of the main interest areas are 'new models of care', particularly multi-specialty community providers and integrated primary and acute care systems, which can be hospital or primary care led. In both models, optometrists can work as part of the multi-professional team, something already happening in some areas, but more so in hospital settings. 

We cannot afford to keep reinventing the wheel.

Over the last 10 years and across the UK, optometrists have been expanding their skills and investing in new technologies, enabling them to take on more advanced roles and responsibilities. An increasing number of optometrists have independent prescribing qualifications, currently 352, and more are undertaking the College of Optometrists' range of Higher Qualifications. Optometrists in the Hospital Eye Service are now routinely working in eye casualty, and in glaucoma and medical retina clinics.

In Wales, optometrists use the Eye Health Examination Wales which has a banded structure. Band 1 enables optometrists to see patients with acute eye conditions, those in at-risk categories for developing eye disease or those who would find losing their sight particularly difficult. Band 2 enables optometrists to conduct further investigations or examinations to help inform their referral, investigate clinical findings or determine management after a sight test. And Band 3 examinations enable patients to be followed up. Currently 92% of practices in Wales offer this extended examination.

In Scotland, NHS prescribing pads were issued at the end of 2013 and over 140 optometrists are now prescribing in hospitals and the community. Here optometrists can conduct a supplementary eye examination to monitor patients and have the option to recall the patient to review the treatment as required. By adopting this model, optometrists can deal with a high percentage of patients in the community. 

Around 90% of optometry referrals to secondary care in Scotland are now direct, whereas it’s the opposite in England. The majority of Scottish Health Boards have introduced electronic referrals, some areas as high as 65% of the total. 

In England, primary eye care commissioning is quite different. The NHS sight test contracts are with NHS England but any add-on schemes, such as glaucoma repeat measures or minor eye conditions, are commissioned by the 200 plus local Clinical Commissioning Groups (CCG), often just for that CCG area. The small scale involved can mean that efforts are often duplicated, and not all optical practices have to participate.  Some patients do not stay within their CCG boundaries for their primary eye care, for example, in my part of London, 20% of patients attend practices outside the CCG area and miss out on the schemes. This is leading to a fragmented and inconsistent system, both for patients and practitioners. 

To achieve better outcomes and a more efficient service, schemes have to be operated at a greater scale. Also, as more optometrists gain their independent prescribing and a NHS prescribing pad, the scope of practice within some of the schemes will widen.

To ensure consistency in the shift from hospital to community services, a framework has been developed by an experienced group of clinical leaders and patient advocates under the Clinical Council for Eye Health Commissioning. The framework was approved last week and will be shared with CCGs and providers very soon. It recommends that a community ophthalmology service should be distinct from primary and secondary care services and the main aims should be the assessment and management of patients whose eye conditions are at low risk of deterioration who are either referred by primary care for assessment, or discharged from secondary care for monitoring. Schemes that are supplementary to the NHS sight test in primary care, that are undertaken prior to the decision to refer e.g. glaucoma repeat measurements, minor eye conditions should not be considered as community ophthalmology but commissioned with separate service specifications. In developing the Community Ophthalmology Framework, the focus has been on maintaining quality, ensuring safe care, reducing service variation and improving equity of access. Given the current capacity issues in ophthalmology services and the pressures on general practice, the status quo is not sustainable and these innovative models of care do need to be tested at greater scale. However, service redesign of this type should not be done in isolation as it will have an impact on the whole pathway.

The Eye Health Network for London report, Achieving Better Outcomes, was launched this week and describes a more co-ordinated approach to the commissioning and delivery of eye health and sight loss services across the capital to support the integration between services and pathways. It includes five priority areas highlighted by the VISION 2020 (UK) Ophthalmic Public Health Committee and a set of 12 recommendations. It could have implications for all the other Local Eye Health Networks in England. 

 

We may still have a fragmented eye care model in England, but change is finally happening. The key now is to learn from the good examples and replicate them at scale where makes sense to do so. We cannot afford to keep reinventing the wheel.

 

David Parkins MSc FCOptom FEAOO
Past President, Trustee, Council Member - London

David was the President of the College of Optometrists from March 2014 until March 2016. He is the Chair of the Clinical Council for Eye Health Commissioning, Chair of the London Eye Health Network and a member of the General Optical Council.

He works in independent and hospital practice in south east London, and works part time as assistant director of quality for the Bexley Clinical Commissioning Group.  He is currently conducting doctoral research into the clinical decision making and the referral practice of UK optometrists.

David is a Fellow of the European Academy of Optometry and Optics (EAOO), a liveryman of the Worshipful Company of Spectacle Makers and has been awarded Honorary Life Membership of Vision Aid Overseas.

 david.parkins@college-optometrists.org
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