We as a profession have long been aware of an overwhelming tide of rising appointments swamping our hospital eye services. Multiple local initiatives have sought to divert a growing number of these to competent optometrists in primary care, providing a lifeline to both overwhelmed NHS staff and to patients worthy of quality care. These initiatives are not only to be commended as both smart and forward thinking, but embraced as the only logical solution to an otherwise disastrous future reckoning.
As primary care practitioners we should first strive for clinical excellence, accurate referral and patient management. However, I believe there exists a conflict of interest in some parts of the profession where optometrists are encouraged to see ever greater numbers of patients, produce high conversions and to upsell lens products. In these situations restrictions on time, the number of tests which can be performed during each eye examination, result in both high numbers of unnecessary referrals and potentially missed opportunities for the early detection of ocular pathology, both of which place further burden on hospital eye services.
The advent of optical coherence tomography largely removes the guesswork from diagnosing a growing range of ocular conditions and potentially elevates an optometrist’s role in the joint management of pathology. However, not all optometrists have the opportunity, inclination or the time to develop their ability to accurately interpret the results of OCT. Not all practice owners have the will to designate funds for such a big purchase, and those who do usually recoup this from the patient through additional fees. This creates potential for a further conflict of interest where the direction of the eye examination is driven by a patient’s bank balance and not their clinical needs.
By acknowledging and demarcating the increasing split in our industry between that of the sales driven agenda, and that of an emerging body of clinically focused practices which invest in new technologies and education, we can better support our hospital eye departments as well as our patients. The potential for shared care is anything but a new proposal and in some regions is taking firm root, however, we are currently seeing a piecemeal roll out of disjointed initiatives instead of a nationwide coherent strategy.
To supplement the explosion of shared care initiatives I propose the creation of nationwide optometric referral centres – designated and accredited practices which triage all but emergency appointments. To receive accreditation a practice would need to meet stringent minimum standards of equipment (including OCT) and minimum competency requirements for ophthalmic performers, with accreditation determined by objective structured clinical examinations. When so much of the hospital diagnosis and management of patients is done in response to objective clinical data it would be a small step for these triage centres to receive complete oversight by ophthalmologists remotely. By reviewing a standardised format of objective data relating to each patient (history and symptoms, visual acuities, fundus photos, Goldmann IOPs, OCT, visual fields, pachymetry, etc), one ophthalmologist could provide oversight for a whole city’s referrals, accurately and remotely joint managing patients. This would result in significantly fewer and more accurate hospital referrals, and therefore significantly shorter waiting times for those patients which need to be seen quickly, while negating the need for a patient who has already received an extended range of tests in primary care, to repeat the exact same tests at the eye hospital.
Optometrists without access to increasingly important imaging techniques can send those ‘just in case’ referrals without the worry of overburdening the hospital eye services. In turn our hospital eye services can discharge stable patients to these eye clinics for monitoring both during treatment protocols and after. Referral refinement and stable patient management could perhaps be extended to include intraocular injections, minor surgery and limited disease management for independent prescriber qualified optometrists. All optometrists should retain the ability to participate in shared care services – initiatives such as IOP referral refinement, Mecs and Pears would all continue to run concurrently and hopefully be expanded.
Fees for the extended range of required tests could be negotiated based on hospital savings and improved patient experience. These would need to be justified based on indications in the patients history and symptoms or findings during the eye test, and not on whether they were convinced to go for a ‘bronze, silver or platinum’ package.
Without concerted unified action to dramatically reduce the number of hospital-related appointments through initiatives such as these, I believe we will see a degradation of our hospital eye services, to the detriment of our patients. These proposals are intended to contribute to the debate on how to modernise our referral pathways by making best use of 21st century mediums of new digital imaging techniques and the ability to instantly transfer this acquired data.
