Liverpool is steeped in history, from its mercantile roots, home to Cunard and the White Star line, to the Merseybeat and Derek Hatton. Not to be outdone, at their annual meeting in the city, the Royal College of Ophthalmologists (RCO) made history with its first day dedicated to Emergency Eyecare. Coming at the end of a four-day meeting and against the backdrop of a change in security risk, it proved to be a really interesting day. The session was the brainchild of the British Emergency Eye Care Society, an ophthalmology-led, multidisciplinary group with emergency eye care as its raison d’etre (www.beecs.co.uk).
Although billed as a multidisciplinary day, I think I was the only practising optometrist, and probably the only non-doctor. I wondered if I was seen as some sort of Trojan horse, infiltrator or spy? Nothing could be further from the truth. Brilliantly led and co-chaired by Seema Verma (Moorfields, the first ophthalmic A&E consultant) and Stella Hornby (consultant Oxford Eye Hospital), the day was pretty much entirely clinical and apolitical.
Placed forefront was the patient, the first presentations detailing the problems arising from the demographic change, patient expectations and the potential perception of inaccessibility due to ever increasing specialisation and subspecialisation of medicine and ophthalmology in particular. Although we in optometry may not realise it, there has been a struggle within the RCO to give emergency eyecare a higher profile. For many years, it was thought of as gatekeeping an ever-increasing number of dry eyes and blepharitis and a job just for juniors in training, with only the occasional ‘stop the clock’ true emergency. No longer.
Do not forget, when optometrists espouse their position and role in primary care, we are not alone. Primary care also encompasses ophthalmic A&E whether that is 24/7 (Moorfields and bigger units) or 9 to 5 (with on call ophthalmology accessed via A&E out of hours) or perhaps nurse led walk-in centres or even phone triage. It seems a working definition is; access without referral. We truly are all in it together. Both of the co-chairs were keen to espouse the role of the IP optometrist. Their only regret was that, when they got their HES optometrists trained, they rapidly got purloined by glaucoma, medical retina and even research. Clearly they felt that when IP placements are provided, the medical teams reap more benefit than it costs.
The point was made more than once that optometrists represent the only practical group existing in any real numbers which do not require huge investment in training. But even with an IP qualification, the consensus was that an optometrist probably needs 18 months of regular exposure to disease to become confident and semi-autonomous. I have to say I agree.
The way forward
Detailing the scale of the problem, John Buchan presented the evidence base behind the Royal College of Ophthalmologists Way Forward project.1 Although there has been some input from HES optometry into the Way Forward project documents covering glaucoma, cataract, and AMD, this is absent from the emergency document. I do wonder if a unified approach, including community optometry, might yield more benefits. I urge optometrists to read this easily downloadable material.1
Although it may not be what we want to hear, and neither Pears nor Mecs were denigrated as such, there is a legitimate concern that we may be generating an increasing unmet need as opposed to taking workload away from ophthalmic A&E. Clearly there is a cognitive dissonance if investment in the CCG funded Pears/Mecs does not produce an immediately visible drop in A&E attendance.
Another concern was that, although optometrists were seen as a capable and well trained resource (and yes they absolutely understood the ridiculous fragmented GOS system which works against a better scope of practice), we may end up, worst case scenario, in being another step in the pathway rather than eliminating steps. The subtext here is that we must not see Pears and Mecs as an end game, more a stepping-stone towards a more integrated approach to eye care.
The Way Forward criticises the accessibility of optometrists providing Pears/Mecs, in that practices are scarce in areas of significant deprivation and the concern is that, colloquially, Pears may generate increased input from those in less deprived areas. To be honest, in comparison to centrally located hospitals I would have thought that accessibility to optometry practices was wider than that of GPs in that they are found in high streets and shopping centres. However, it is certainly possible that the less well-equipped optometrists may be closer to the deprived areas. This issue is not unique to optometry as it affects community pharmacies which require subsidy of smaller outlets in areas less attractive to supermarkets.
An interesting perspective on GP involvement was that GPs love Pears/Mecs, so much in fact that they delegate its signposting to reception which means that once it is up and running they delegate everything. While this is great for the schemes, and both patients and GPs love Pears/Mecs, in a tiered cost system it must be remembered that although we may be cheaper in unit cost than ophthalmology, we are certainly not cheaper than a seven minute (if you are lucky) GP exam.
Buchan detailed the process of researching the project (200 telephone interviews with ophthalmologists across the UK). Part of the issue with increased numbers arose with the change in GP contract in 2004. This released GPs from a responsibility to maintain out of hours service with commensurate effect on patients. Thus A&E became a preferred route for access (figure 1). Ultimately we are in a world described by Professor Carrie McEwen as ‘a perfect storm of increased demand, caused by more eye disease in an ageing population requiring long term care’.
Figure 1: Annual accident and emergency attendance by year
So what is emergency eyecare? A useful definition is:
‘Any eye condition that is of recent onset and is distressing or is believed by the patient, carer of referring health professional to present an imminent threat to vision or general health.’2
To further understand the issues Buchan showed that there were mutually opposing forces leading to current pressures (table 1).
Table 1: Opposing influences on emergency eye care
I came away with a new understanding of the nuances to the constructive objections that LOCs, Locsu and other colleagues might meet when a CCG engages with local ophthalmology. An interesting quote in The Way Forward seemed to make sense to me.
‘It has to be better for our patients to see someone with a four-year training, and many years’ experience with the eye, who has a slit lamp and possibly an OCT, rather than seeing a GP practice nurse of someone in A&E who may have only a few hours training in the eye.’
My experience
I attended the meeting with Ben While the newest consultant ophthalmologist at Hereford. A sign of the times, I was welcomed to Hereford as a new optometrist by his father Adrian, with whom we worked on many primary care developments. Ben is one of the new crop of ophthalmologists who recognise the value of taking emergency eye care seriously and of using optometrists as part of the team.
From a starting point of zero, Hereford Victoria Eye Unit now has four sessional optometrists providing support in outpatients and casualty. The Victoria Eye Unit has been amazing, for a small unit to have provided placements for seven IP optometrists is nothing short of unique. By cross-fertilising in this way and with those optometrists retaining their foothold in the community perhaps provides the bridge whereby we can start to help reduce rather than increase the burden. Certainly, in the past three years, Hereford has seen a 5% year on year reduction in A&E attendance since Pears, which given that it was growing at 5% per year is a very significant reduction.
Much was made of the meeting of having access to senior clinical staff when the going gets tough. We optometrists have to remember that even when working as IP in casualty we are not trained on a medical model and though rare there are enough challenging conditions, ophthalmic and systemic, that can creep up and bite. Do you know what tests to order, when and how to ensure they are followed up to outcome? This is not prominent enough, in my opinion in the IP courses.
Did you know for example that TB and syphilis are more common than you might think? A quote that stuck in my mind was that there is currently more TB in Brent than in the whole of Malawi.
Nick Rumney is an independent IP optometrist practising in Hereford.
References
1 The Way Forward. Royal College of Ophthalmologists. 2017. www.rcophth.ac.uk/standards-publications-research/...
2 Commissioning better eyecare: Urgent eye care. The Royal College of Ophthalmologists / College of Optometrists www.rcophth.ac.uk/wp-content/uploads/2014/12/urgen...