Elderly people are pushing back the boundaries of age. You are more likely to find those in their 70s down their local gym or doing voluntary work than relaxing in an armchair with a slice of cake.
But one thing the elderly can’t seem to defy is declining eye health. According to research group Mintel’s Optical Goods Retailing Report once over the age of 45, the majority of people need vision correction, reading glasses or more complex lenses such as bifocals or varifocals.
Given the expected rise in the UK’s elderly population – a 9.1 per cent jump in the over 65s between now and 2019 – opticians are set to benefit from older people’s increased need for and attitude towards optical services.
Mintel senior retail analyst Jane Westgarth says older consumers are more likely than average to have had an eye test in the past year and are more willing to pay more for their eyewear to get a ‘better quality and fit’.
Simon Grier, communications manager at the General Optical Council, sees other benefits particularly in the treatment of diseases more prevalent in the elderly such as cataracts and glaucoma.
‘It may present opportunities for opticians to carry out more enhanced services. The ageing population will put an increased pressure on hospital eye services, which optometrists and dispensing opticians can help alleviate by carrying out certain services in the community – for example, the management of glaucoma,’ he says. ‘Our ongoing strategic standards review will ensure that our standards are flexible enough to allow practitioners to do this. It is important too that we consider the education of optical practitioners – both undergraduates and throughout their careers – to ensure they’re equipped with all the skills and knowledge they need.’
Changing attitudes
Opportunities then but also major challenges for the profession not just internally but also in its public interaction.
‘It requires a shift in public understanding about the role that opticians can play in tackling eye health problems. In our recent public perceptions research, only 19 per cent of people said their optician would be their first port of call if they had a problem with their eyes, compared to 54 per cent who said it would be their GP. Many people only associate opticians with sight tests and selling glasses,’ Grier adds.
David Craig, policy director at the Association of Optometrists, also sees relieving the strain on the NHS as a key role optometrists can play in an ageing UK. ‘More patients will be seeking eye care from a system that is already over-stretched. The solution must involve greater use of community optometrists to deliver care in order to take the strain off the secondary sector,’ he states.
Such primary care includes patients with red eye or foreign bodies ‘going as a matter of course to their local optometrist who will be funded to see/treat/refer/monitor them, as appropriate. If the services weren’t commissioned, these patients would go to their GPs who would, in many cases, have no option but to refer them, increasing the drain on NHS resources’.
He says this is already happening in Scotland and Wales. ‘The devolved governments, through their health departments are investing in the commissioning of community practices. In other words, optometrists are being used as the equivalent of GPs for eyes. Both systems have a very good record at keeping lower risk patients out of secondary care and leaving hospital clinics for those that need them.’
Indeed the Scottish government has a £50m three-year funding plan to support front-line community care. It includes a range of services such as a £1.5m provision of pachymeters for all Scottish optometrists, enabling them to screen for patients suspected of developing glaucoma.
The Scottish Intercollegiate Guideline Network also recently published a guideline for ‘Glaucoma referral and safe discharge’.
This recommended new criteria for the evaluation, monitoring, referral and discharge of patients with signs of ocular hypertension or glaucoma.
Under the system optometrists decide which patients to retain and monitor in the community, who to refer to the Hospital Eye Service (HES), and what information should be included in the referral.
Some training is required to familiarise optometrists with the Spaeth’s Disc Damage Likelihood Scale, plus a refresh of anterior angle assessment, central corneal thickness measurement and visual field tests and results analysis.
‘Previously when an optometrist detected glaucoma in a patient they would be sent to secondary care. They would sit in four-hour long queues just to see an ophthalmologist for 10 minutes,’ says Lanarkshire based optometrist Dr Scott Mackie. ‘But we have the kit, the expertise and we can monitor them. It is a paradigm shift in care and takes expense and burden away from the NHS and ophthalmologists. We are working closely with them and talking the same language.’
[CaptionComponent="1622"]Other developments, Dr Mackie explains, include reduced waiting times for cataract operations and allowing optometrists to independently prescribe licensed eye-related medicines direct to patients without having to visit their GP. Diabetes detection and low vision treatment are next in line.
‘The prescribing saves a referral to a GP,’ he says. ‘In fact in Scotland there are signs up in GP offices saying we don’t see eyes. We are now the first port of call.’
Do the public fully understand that yet? ‘We do need a public awareness campaign. At the moment people find out by default through visiting their GP,’ Dr Mackie says. ‘In terms of optometrists some might say I just want to concentrate on sight tests but others are really wanting to step up and learn more. All the younger ones coming through training will soon see this as standard.’
But what of England?
Craig of the AOP says that NHS England has acknowledged the problem but needs to start working on providing the solution.
‘In England, commissioning of community services is piecemeal. Some areas have no community services commissioned locally at all, leaving GPs to manage the patients, which as many of them have only a basic knowledge of eyes and lack of equipment, they are not well positioned to do,’ he states. ‘It is a haphazard approach to commissioning.’
He says there are 208 clinical commissioning groups and that each one needs to be persuaded that it is a good idea to commission a service.
‘If commissioning must be done locally, as is government policy, there needs to be ways in which resources can be made available to assist the process and pressure applied centrally to encourage the CCGs to commission community eye care services, to do it by coming together in clusters, rather than each CCG commissioning in isolation, so that economies of scale can be made. Training would be helpful – but optometrists could do so much using just core skills.’
Philippa Simkiss, head of evidence and service impact at RNIB, says treating the elderly goes beyond skills. ‘The knowledge of elderly diseases is there. We would like to see more opticians get involved in the patient pathway and have more understanding of where locally a patient can be referred to. We want to see more local partnerships developing,’ she says.
The RNIB says it is working closely with Public Health England and NHS England. ‘A lot of good partnership working has begun but we need eye health to escalate up the public health agenda,’ she says.
Last year NHS England launched a ‘Call to Action’ across the sector to focus on a ‘more preventative approach, early accurate detection by primary care services and effective management in the community’.
A NHS England spokesperson says: ‘We received a wide range of responses and these included the need for nationally commissioned eye care pathways. Many of the key themes and points made in the call to action fed into the overall aims of the Five Year Forward View, which sets out the vision of the future of the NHS. There are tried and trusted communication channels between NHS and the optical profession in order for us to progress the key themes.’
The spokesperson says there are a number of vanguard pilots in England looking to integrate services and to ‘move away from the old primary/secondary care boundaries where these act as a barrier to efficient integrated services. The devolved work taking place in Manchester will also have valuable lessons for future eye-care commissioning decisions’.
More NHS work
Optical practitioners in England are alive to the issue of an ageing population. Dipak Rana, optometrist at Uxbridge based Denham Opticians, says its local elderly demographic has meant in recent times ‘more NHS work, more pathology, increased AMD checks required and increased cataract referrals’.
He says: ‘We have to know referral pathways for certain conditions. But for home bound patients it is logistically not viable to go to intermediate care. They require more regular checks and we have to write lots of reports to the GP and eye departments to OK any management.’
Denham offers home visits to older patients over the age of 80 but due to high costs is not an area it is looking to expand. Jeremey Topliss, owner of Halifax based Mackereth Opticians, has seen a steady increase in elderly patients over the last 25 years with many more patients over 90 plus.
‘We are part of Calderdale’s locally enhanced services and offer diabetic retinopathy screening, a cataract referral scheme and glaucoma refinement scheme. Our dispensing optician is undertaking a course on low vision aids in the hope of offering more advice to patients in the future,’ he explains.
More recently Calderdale Council has set up a PEARS scheme for emergency ocular conditions, where the public can get a same day appointment to see an optometrist.
‘Many local GPs are using this service now to refer their patients with ocular problems, rather than sending them to A&E or the local ophthalmology department,’ Topliss states. ‘The participating optometrists in these local schemes must attend further training events, that are held periodically. The scheme is advertised in GP surgeries and pharmacies as well as optometry practices. We have recently become involved in a new scheme for follow up of ocular hypertensives that the hospital are happy to have monitored by optometrists. But I feel more widespread advertisement of these local services would be beneficial.’
