One of the difficulties that commonly faces optometric clinicians is the interpretation of patient images obtained via various imaging devices.
There are a number of forums available to optometrists where they can upload their retinal images for a peer-to-peer opinion as to what it is they are looking at and what they should do regarding their patient.
While these peer-to-peer forums can be very good and very helpful, quite often the outcome is that the patient gets referred anyway. Now this may be a good thing but the question often arises as to just why the referral is being made and is it being made just to cover the back of the clinician?
Such an occasion arose the other day on the Optomap mailbase where the decision to refer prompted a response from one contributor asking this very question and adding the comment: ‘Ought we to get together with the RCOphth [Royal College of Ophthalmologists] and get some joint thinking on this?’
Given the parlous state of outpatient ophthalmology services and the crisis facing this service, as recently outlined by Adam Sampson, CEO of the Association of Optometrists, the last thing we in primary care should be doing is exacerbating the problem in secondary care.
Often my thought is that these problem images could be shared electronically with a local ophthalmologist for their advice and decision as to whether they wish to see the patient or not. This, to me, seems eminently sensible and a good use of everyone’s time. But is it happening?
For quite some time now an NHS initiative has existed, of which many of you are probably aware. For those who have not heard of it, it is called ‘Advice and Guidance’.
The aim of this was to reduce the backlog in secondary care outpatient clinics by requiring what the NHS termed primary care to offer advice and guidance to patients thereby reducing the need for referral.
The system utilised an exchange between a GP in the primary care setting and a specialist in secondary care to discuss the potential referral and thereby possibly avert an unnecessary referral into secondary care.
Sadly, reading many of the reactions from GPs, many just saw this as another burden on their time and reading some of their comments in Pulse magazine many do not seem to have embraced the system.
At this point I want to set aside the funding issue as, of course, when the NHS talks of primary care it means only GPs, and ask the question as to whether such a system works between primary care optometry and secondary care ophthalmology?
On the surface it would seem that the ability for an optometrist to feed the relevant patient symptoms and history along with exam results and electronic images to an ophthalmologist with a request for guidance or an instruction to formally refer would seem a major breakthrough in patient handling and inter professional working that would seem to create wins on both sides.
So, what are the chances?
The really good news is that this type of working seems to have been greeted with enthusiasm by both professions.
In a document jointly published in August 2021 and due for review in July 2022 issued by the Royal College of Ophthalmologists and the College of Optometrists entitled, Ophthalmology and Optometry – Our vision for safe and sustainable patient eye care services, the idea of Advice and Guidance is championed.
I urge everyone to read this document. It states among other things:
‘Systems should be developed to take advantage of the expertise and facilities in primary care to allow patients to be managed in primary care optometry, with HES input as required. For new non-urgent referrals: utilisation of recognised pathways should be put in place for referral filtering and refinement by primary care optometrists, including advice and guidance for primary care optometrists and GPs, with accessible support from the HES. For urgent and emergency referrals: hospitals should provide accessible timely triage for urgent referrals and advice and guidance for primary care optometrists and GPs.’
Of course, the issue of connectivity and costs is not addressed here but the fervent wish by both Colleges is for this to happen, and there is specific mention within the document of the need for equitable funding.
So, for all of us who find ourselves in a position of not always knowing what to do with a patient in the light of images we may have obtained, there is a potential for meaningful service development in line with the modern direction of NHS travel. Will it happen? I would urge you to approach your LOC to get it to find out from both the RCOphth and College just where things are in your locality now.
Maybe even get the LOC to get a briefing from Locsu. Good work is potentially afoot but implementation is needed as a matter of urgency. Will the NHS mandarins have the willpower to make it happen? With National Eye Health Care Week just behind us maybe now is the time to really rattle the cage of the NHS mandarins.