A critical viewpoint on the referral of eye patients from high street to hospital has been opposed by the profession but served to stoke an important debate about the provision of eye care amid widespread NHS reforms.
It was unlikely consultant ophthalmologist Michael Clarke expected such a response when he wrote in British Medical Journal last week that ‘UK law leads to opticians making too many referrals’ (News page 5).
Central to his argument was section 26 of the Opticians Act requiring optometrists carrying out NHS sight tests to perform such examinations of the eye for the purpose of detecting injury, disease or abnormality, before providing a written statement on whether the patient was being referred.
Clarke said this was being interpreted to mean they had a responsibility to refer any abnormality, but optometrists including Nick Rumney stressed there had been no obligation to refer since 2000 when the GOC rules of referral changed. He instead blamed the NHS sight test contract for the tendency of some, but not all, optometrists to refer at a lower threshold.
‘Optometrists are in a unique position to hold back the very patients Mr Clarke does not wish to see as they are potentially not only the gatekeeper for referral but also the source of community treatment that is simply not practically possible in general practice for the reasons he espouses,’ added Rumney.
The Royal College of Ophthalmologists was also quick to react on the matter last week, stressing Clarke’s views ‘may not be held by all ophthalmologists’ and that the 30 per cent figure quoted for inappropriate referrals also equated to 70 per cent of appropriate referrals.
Nevertheless, with mounting pressure on the NHS to cut costs and waiting times, the RCO called for a joint endeavour to reduce the number of unnecessary referrals.
RCO president Professor Harminder Dua (pictured above) said: ‘The College [RCO] is concerned with the restricted practise in appointments to Local Eye Health Networks (LEHN), the governance structure of these bodies and the trend towards awarding eye healthcare contracts without the involvement of ophthalmologists.
‘It must be recognised by all concerned that eye healthcare is not just about primary care. LEHNs and commissioning groups should include ophthalmologists in planning eye care services.’
Professor Dua acknowledged the limitation of capacity within eye departments and warned not to underestimate the contribution that optometrists made in looking after the basic eye health needs of the population.
‘We have the lowest ratio of ophthalmologists to population within mainstream Europe. An ageing population and newer treatments becoming available through advances in medicine and surgery and approved by NICE are putting immense pressure on existing capacity.
‘One approach to deal with this problem has been the organisation of shared care programmes with optometrists, which are ophthalmologist led. There are several good examples of this across the country.
‘Given the large number of qualified optometrists, optometry and GP practices in the country with “walk-in” access means they are the natural first port of call for many patients with eye ailments. They are encouraged to have a low threshold to refer to the hospital eye service with a view that the patients’ best interest is served.’
New president of the College of Optometrists, David Parkins (pictured), was also keen to respond on the referral issue and said all services needed to find ways to improve capacity and outcomes while reducing waste.
Parkins said: ‘Research by patient groups has found that most hospital eye units are already unable to treat patients within the recommended times that would minimise their risk of sight loss. As part of reducing waste, there is always more that primary care clinicians can do to improve the quality of their referrals.
‘However, the answer lies in more integration of primary and secondary eye care services rather than less. Community eye care services, such as those recommended by NICE for glaucoma, work best when their IT enables feedback on referrals for example. The RNIB has warned that preventing optometrists from referring directly to hospital eye services or from using electronic referral can lead to delays in starting treatment and may permanently lower visual outcomes for patients.’
Meanwhile, Parkins said the introduction of LEHNs across England was an opportunity for all eye health clinicians, patient groups, public health practitioners and commissioners to work together.
‘We echo the Royal College of Ophthalmologists’ call for their members to take an active role in the networks to ensure that the integration and quality of eye health services continues to improve, and help the NHS in England meet its significant eye health challenge by reducing avoidable sight loss,’ he added.
Meanwhile, another perspective on the debate was offered by Pat Cameron Davies, honorary secretary of The Association for Independent Optometrists and Dispensing Opticians, who pointed the finger at free eye tests.
She said: ‘We all know that the business pressures for the large optical multiples to compete with one another have resulted in cut price “professional care” meaning the chair time given to each patient whether private or NHS can be severely restricted. In a bid to save wasting “commercial” chair time are professional staff being instructed by their managers to immediately refer patients with any ocular abnormalities?
‘This whole issue of “free” eye tests needs to be addressed by the College, GOC and AOP before our profession falls into disrepute.’
