Reform of optometry services in Wales will take place after a contract was agreed between the Welsh Government, Optometry Wales and NHS Wales.
Changes will be aligned to the commitments set out in A Healthier Wales and the Future Approach for Optometry Services reports that outlined how to improve access to eye care.
The new contract focused on enabling patients to receive services that were delivered by the right professional, in the right place across the entire eye care pathway.
In a statement confirming the agreement, Eluned Morgan MS, minister for health social services, said: ‘The increase in clinical services delivered by optometrists, working together with hospital eye departments, will provide NHS Wales with assurance that delivery will be equitable, consistent, and timely for all citizens across Wales.’
During rollout, Morgan added that the priority would be to implement services that reduced the number of referrals and improved access into hospital eye departments.
‘This policy development ensures Wales remains at the cutting edge of the UK, leading reform clinically from a patient centred perspective and being the first UK nation to fully embrace clinical services in optometry primary and community care,’ she said.
Patient expectations
Sali Davis, chief executive of Optometry Wales, explained to Optician that patients would receive eye care from their usual optometrist or dispensing optician, or from another primary care-based practice. ‘Patients will be provided with an individual management plan and can expect to have conversations around their general health, such as smoking and diabetes. All the legislative changes are fully supported by our consultant colleagues, who have been working with us for many years in provision of shared care in Wales,’ she said.
The new optometry contract will see the creation of Wales General Ophthalmic Services (WGOS) with the baseline level of service provision including an eye examination together with Wales Eye Care Services as part of the Level 1 and 2 services to patients.
‘All practices will be expected to provide Wales Eye Care Services. Wales Eye Care Services still covers our optional Low Vision Service Wales and the Eye Health Examination Services Wales,’ Davis explained.
Davis said other non-mandatory additional levels would be offered to patients, which would require higher qualifications in independent prescribing, medical retina and glaucoma. ‘The focus will be on keeping patients out of secondary care. These are not mandatory services but what this will mean is that inter and intra practice referrals will become mandatory where appropriate,’ she added.
Legislative change required for the work covered by WGOS1 and the associated voucher value amendments will come into effect in 2023, while payment for levels 2,3,4, and 5, payments for clinical governance, quality improvement compliance and the cluster payments started immediately.
Davis said: ‘We are keen to reassure practices that there will be a phased implementation to contract reform. Funding for the higher qualifications will continue and we will see Health Education Improvement Wales continue to support and mentor the profession in Wales and taking more of an active role in supporting the mandatory aspects of contract compliance.’
Top of the licencee
Previously, Davis explained, the narrow terms of service that Welsh optometrists were working to meant that all a practitioner would need to do was ‘detect and refer’ any ocular abnormality and provide a refraction. ‘Legislation will change to incorporate the Wales Eye Care Service and allow optometrists and dispensing opticians to operate at the top end of their licences.’
Additionally, occupational health provision will be available as well as increased CPD payments according to what level the optometrist or dispensing optician operates at. ‘What will also change are voucher values, the main focus for contract reform is to offer our clinicians in Wales a fair fee for fair work and to minimise what has plagued the profession for so long; the cross subsidy on sales of glasses and the need to sell glasses to cover costs for the clinical work undertaken.’ Davis added it would not remove the cross subsidy but fees would increase considerably. ‘This will hopefully allow us to see more patients who would have previously been seen, diagnosed, managed and treated in secondary care. A patient will now expect to have their care delivered within a primary care setting.’
A new contract for eye care provision in Wales has the potential to create positive change in the other home nations, Davis suggested. ‘We are confident that what we are doing in Wales will be monitored in other nations and best practice shared. Services that have been running in Wales for some time have been evaluated and this evaluation and published research has led, in part, to the creation of the WGOS,’ she added.
Serious concerns
Concerns have been raised by the Association of Optometrists (AOP) about the new funding model announced as part of eye care reforms in Wales.
The professional body said while it welcomed the increase in fees, it had serious concerns over the proposed funding model.
Adam Sampson, chief executive at the AOP, said: ‘We welcome the fee uplift which recognises the value of the clinical skills brought by optometry and the contribution of primary eye care to patient experience and outcomes.
‘A move away from a reliance on retail to one of specialist clinical examinations is absolutely the right direction if we are to tackle the growing patient backlog in real terms. However, looking at the detail of the package presented there is some fundamental work that needs to be done to understand what the sector is being paid for, and whether that represents true value.’
He added that the AOP was worried about how the fee was intended to cover a greatly expanded service and sought assurance that this was not the case.
‘An additional area of concern is for those members providing domiciliary services and if they will benefit from the uplift, as this is yet to be revealed in the plans. The reduced voucher value for some patient groups also represents a retrograde step that limits patient choice and access to eye healthcare. This is deeply concerning at a time when people are already struggling to make ends meet in a cost of living crisis,’ Sampson said.
AOP concerns rebuffed
However, Davis said Optometry Wales did not share these concerns and all stakeholders were involved in shaping what the contract would look like since the start of the process in 2018.
‘Part of the success we have had in Wales with enabling the profession to move forward previously is because of work we have done in documenting key patient outcomes. The proposed changes were introduced as part of a patient-centred approach document and bring together the information and data we already collect as part of the sight test.
'It allows a risk-based approach to be taken to the management of eye conditions and places clinical decision making at the centre of the approach. Prevention and wellbeing conversations are already part of the conversations that optometrists have with their patients. The changes that are being introduced allow these to be formally recognised in order for us to understand more and plan better for the care of our patients for signposting on to other services.
‘What might be included is all part of the continued programme and discussion for contract reform, which will be carried out at implementation groups that are made up of representation from the sector in Wales (Optometry Wales), Welsh Government, Health Boards, Health Education Improvement Wales and patient groups.
'In answer to concerns around domiciliary services, the new WGOS services will now expand the clinical services offered by domiciliary providers with the introduction of EHEW services as the baseline service provision. This allows domiciliary providers to take advantage of the move towards clinical services, treating and managing more patients in primary care. Patients in Wales should expect the same standard of care whether they are examined in a fixed premises practice or a domiciliary setting. The WGOS services will remove the need for a notice period to be provided to ensure acute eyecare can be delivered to the entire population.'
Davis said a new fee of £43 had been agreed for the eye examination and all other services have had uplifts with no change to service requirements. ‘A practice delivering services requiring higher qualifications will attract fees of £125 for a first appointment and £62 for a follow up. AOP members have reacted extremely positively to this announcement,’ she said.
When asked by Optician if the increased fee went far enough, Davis thought that it did and added the increase was a reflection of the value that the Welsh Government placed on the profession. ‘A recognition of the valuable role of the profession in correction of refractive error and the crucial role we play in detecting ocular abnormalities,’ she added.
‘Welsh Government’s aim was to address in part the cross subsidy in optometry. They have chosen to do this by increasing all of our clinical fees to properly reflect skill whilst still allowing an opportunity for private work in primary care. The adjustment of the voucher values reflects the costs of providing an optical appliance and should not be taken out of context with the whole system change. The new voucher system also sees the current inequity addressed, particularly at the higher prescription ranges where we know the value of the voucher does not cover the cost of supply. The Welsh Government have significantly increased the funding to primary eye care services which results in a substantial increase in fees paid to optometric practices for the full range of services that we know they can provide.
'This will take the profession some time to adapt to, but with an increase in the overall funding provided to practices, why would practices reduce the choice that they offer their patients? For those practices who chose to dispense, they will need to provide an optical appliance to a patient who is in receipt of an optical voucher, in this way patients will have equal access to appliances across Wales to ensure that their eye health needs are met. It is expected that you will still retain the option of providing private services and appliances additionally if the patient wishes to and is able.
'The use of optometrists with additional qualifications in medical retina, glaucoma and independent prescribing will reduce the number of referrals into hospital eye care services and enable the co-management and discharge of patients currently under long-term review in our secondary care services. Access to eye health care will be improved by the utilisation of the skills of our primary care workforce, ensuring that only those who need specialist hospital eye care services will be seen and improving timely access to this important resource.
‘Our fees will now be reviewed annually and always brought in line with inflationary increases. We are now being treated in the same way that our other primary care contractors are with payments covered for occupational health, our clinical governance, increased payments for CPD with additional supplements if you hold higher qualifications and payments for undertaking quality improvement audits. Optometrists will be paid to be part of primary care clusters and 60 new roles will be created for optometric leads to support cluster work.’