The demand for eye care services is predominantly growing due to an ageing population. Hospitals are struggling to meet this increased demand, which is compounded by recruitment challenges.
While the challenges are the same across the UK, in Wales we want to transform the way services are accessed and delivered by utilising the skills of primary care optometrists. The upskilling of optometrists has evolved over time in Wales.
We recognised the increasing gap between the demand for, and capacity to provide specialist hospital eye care services, and decided to utilise our already skilled optometric workforce to support colleagues in secondary care.
Eye care initiatives launched in 2002 brought together a Primary Eye Care Acute Referral Scheme and an enhanced examination for groups at risk of developing eye disease. This scheme developed to become the first point of contact for acute eye conditions with optometrists managing a range of non-sight-threatening conditions, immediately relieving pressure on GP practices.
The introduction of low vision services enabled us to move all patients from hospitals into primary care to deliver the service. Optometrists and dispensing opticians can determine if low vision aids will help someone living with reduced vision reach their full social and educational potential.
In 2016, optometrists were upskilled to deliver Band 1, 2 and 3 examinations. These enhanced services have benefited patients across Wales, improved outcomes and access, and enabled optometrists to become the gatekeepers to hospital eye services.
Services in 2023
Building on the success of these changes, the Welsh government brought together all stakeholders through a series of meetings in the autumn of 2019 to determine what eye care services would look like in 21st century. This resulted in the publication of the NHS Wales Eye Health Care – Future Approach for Optometry Services and formed the principles underpinning the proposals for the new optometry contract and terms of service currently under development in Wales.
As part of the engagement event, the outdated mixed retail model of providing eye care in optometric practices was rejected with calls to financially support clinical services and remove the reliance on the sale of optical appliances to support the business model.
Other disadvantages of the current retail-led system were highlighted by stakeholders, which included: insufficient capacity to address clinical issues, with few clinic slots available during the day for urgent/eye care appointments; reduced access for patients with acute eye problems, who are often redirected to other optometry practices to receive eye care; reduced access for children, with increased waiting times compared to adults who are perceived as more profitable; sales pressures driving the wrong clinical outcome for patients through prescribing habits; and financial incentive for businesses within the voucher system and the sale of optical appliances, not through the provision of clinical services.
We heard how the profession wanted to improve the perception around accessing optometry services, upskill clinically and work with secondary care services to improve access, reduce waiting times and improve patient outcomes.
Our proposals build on the clinical progress we have seen in Wales over the past 20 years. The key principles centre on the delivery of eye healthcare, reducing demand on hospital eye services and enabling co-management and discharge of patients from the hospital by introducing clinical pathways that utilise optometrists with additional higher qualifications in glaucoma, medical retina and independent prescribing.
In addition, there is an emphasis on prevention and wellbeing across all primary eye care pathways and raising the minimum standards so all optometry practices provide eye health examination services.
The proposed new primary eye care services and remuneration would reflect the extent of additional time and skills required to undertake each clinical interaction.
Embracing change
To address the issues identified, a significant whole system change is thought to be required. In the 2022 negotiations, it was agreed there was a need to change business behaviours by shifting the financial incentive into clinical areas, while protecting patient access to essential correction of sight.
It was considered that viability for providing NHS clinical services should not be dependent on a practices’ ability to drive sales and the Welsh government should look to address this through contract reform.
The evolution of Welsh eye care to date has been shaped with improved patient outcomes and access to clinical services at the very centre, with an appetite for improved collaborative working from primary and secondary care services alike.
These aspects have underpinned the development of the proposals for the reform of Welsh optometry and will continue to drive future expansion of services.
The proposals to expand optometry services in primary care are now out for public consultation. We encourage everyone to have their say.
- David O’Sullivan is chief optometric adviser to the Welsh government.
