Millions of missed appointments, cancelled follow ups and a collapse in referrals were the consequences of the pandemic period on clinical eye care services across the UK.
This bleak picture of optics was painted in stark detail with the publication of The State of the UK’s Eye Health 2021 last week. The report, commissioned by Specsavers, and carried out by Deloitte Access Economics, relayed in grim minutiae how eye care services were withdrawn, cancelled and restricted in the face of the Covid pandemic. An already stretched eye care services community saw the number of routine eye examinations plummet by 23% in 2020 compared with 2019. That was a massive 4.3 million eye tests not carried out leading to huge knock-on effects for the whole sector. Referrals in the nine months to December 2020 fell by 316,000 on the same period a year earlier. Glaucoma referrals fell by 43,000, of which 2,600 might have expected to require urgent treatment, over 10,800 wet age-related macular (AMD) sufferers failed to make it to hospital while 6,133 diabetic retinopathy cases stayed at home.
Those already within the hospital sector also saw treatments dry up. Declines of 36% and 43% were seen on ophthalmology outpatient attendances and day case procedures respectively in the same nine-month period. The list goes on. Despite the Royal College of Ophthalmology’s advice to continue anti-vascular endothelial growth factor therapy injections for age-related macular degeneration (AMD) around 10% were delayed; NHS glaucoma follow ups fell by 11,062, injections for diabetic retinopathy by 8,680, wet AMD injections by 6,313 and a whopping 235,000 eye surgeries were missed or delayed. The result is that an additional 2,986 people lost vision as a result.
To gauge the economic cost of the sight loss the authors estimated that, if the backlog built up during the pandemic took three years to clear, people would spend an additional 57.2 million days on waiting lists. This was estimated to cost the economy an additional £1.7bn on top of the £36bn sight loss is already estimated to cost the economy.
Later stages
Speaking at an online event launching the report, Giles Edmonds, Specsavers clinical services director, said optometrists in primary eye care were seeing increased levels of disease often at a later stage than would normally be found, leading to more complicated cases. ‘As things get back to normal we will uncover a large amount of disease. Thousands of people’s vision is now at risk due to missed appointments.’ He said this was just the tip of the iceberg and patients would continue to turn up in practice with more serious vision problems. This, he said, will have a huge impact on the health service and the economy for many years to come.
Giles Edmonds, Specsavers clinical services director
While the figures above paint a bleak picture, Edmonds said by working together optometry and ophthalmology could develop new ways of working and solutions for patient-centered care. The report highlighted great examples of how professionals can work together to provide the best outcomes for patients. ‘The pandemic has had a huge impact on the nation’s eye health but the silver lining could be that we find better ways to work together for the benefit of our patients,’ he said.
Specsavers’ founder Doug Perkins praised his staff for going the extra mile for patients during the pandemic, and added that no one could be in any doubt about the impact of the last 18 months. He said communication was key and that was why Specsavers had commissioned the report and would be taking a leading role in National Eye Health Week to get the message about the need for eye care across to the public.
‘The optometry profession has an unprecedented opportunity to make a positive difference by working together with GPs and ophthalmologists to reduce preventable sight loss. Together we can work to reduce pressure on an already overburdened NHS.’ Perkins also said a joined-up community approach and adoption of the latest technology offered patients a more convenient and accessible service.
The report was launched at a webinar hosted by TV’s Sue Perkins. She took questions from an online audience posed to the event’s panel of experts. Professor Bernie Chang, president of the Royal College of Ophthalmologists was asked about the effect of the pandemic on the hospital sector. He said it had a huge effect. ‘When the first lockdown occurred routine eye care in hospitals stopped,’ he said, as resources were diverted and people tried to avoid infection. Treatment soon became confined to emergencies or potential sight loss cases. He reiterated that even before Covid there were capacity issues and new ways of working were needed. ‘We have to build and increase capacity in order to prevent sight loss.’
Professor Bernie Chang, president of The Royal College of Ophthalmologists
Backlog
Optometrist Zoe Richmond, clinical director at Local Optical Committee Support Unit (Locsu), was asked by host Sue Perkins about the role clinical commissioning had to play in tackling the backlog and the role of charities. She said, as an independent optometrist serving a small rural community for 25 years, it was important for everyone to come together to form a solution. ‘More of the same will not be enough,’ she said, adding that even before Covid demand was not being met. ‘Covid has accelerated the challenges.’ She said the National Eye Care Recovery and Transformation Programme (NECRTP) had been developing a suite of clinical care pathways that were for the use of the whole of the primary eye care community. Her work with NECRTP showed the way forward, but, she admitted: ‘That’s the easy bit.’ What was needed now was a commissioning framework to support the delivery, foster collaborative working and remove competitive issues. Charities needed to be included as early as possible in the process.
Paul Morris, director of professional advancement at Specsavers was asked by Perkins what community optometry could do to address the issues raised in the report. ‘We’ve long known things need to change within eye care. The backlog was building pre-Covid and the pandemic has made it so much worse.’ He said hospital and primary eye care services were on the verge of being overwhelmed. He said, rather than ‘pockets’ there were vast swathes of excellence throughout the UK demonstrating joined up working and new ways of thinking that can help solve the problem. This meant more optical practice staff training to assist their hospital ophthalmology colleagues to relieve the pressure on the hospital service, he explained. Patients could be treated in their community and there were fewer journeys to hospital. ‘We need to further those innovations,’ he said.
Report lead, Philippa Simkiss described the additional costs of £2.5bn as ‘alarming’. The sheer numbers involved were striking as was the legacy. ‘We know 3,000 people suffered permanent sight loss as a consequence of the pandemic,’ that has a huge personal and financial cost. Patients expect to see joined up care between all eye care sectors so collaboration was key.
The chair asked what the biggest challenges were to achieving collaborations and Prof Chang said improving capacity and access were necessary if patients were to be managed in a timely manner. ‘The quality of care can’t be challenged so we also have to train the future workforce.’ That meant finding those pathways through community, primary and secondary care to meet patient needs.
He said schemes to deliver non-complicated post-cataract patients back into the community for optometrists to look after were being explored through national strategic bodies. ‘This will free up capacity in the hospital for us to focus on more urgent eye conditions. This is where we can work well with the College of Optometrists as well as the independent sector.’
The challenge for optometry, said Morris, was to embrace the technologies and ways of working needed and to communicate the need for eye care to the public. ‘That will save a lot of sight loss in the future.’
Richmond agreed that the profession does not promote itself enough. ‘We all have a role to play. In primary care we think everybody knows what we are doing, but it’s not true, there are a lot of people who don’t.’ She said things like National Eye Health Week were great at getting important messages across and everyone in optics needed to engage with local optical committees and local ophthalmology teams. ‘We need to understand what keeps them awake at night.’
Drawing them back
The chair asked how reticent patients could be encouraged to seek eye care. Richmond said there was a role for domiciliary care, which many patients were not aware of, and technology. Prof Chang said his wish was that any patient, anywhere, would have access to timely eye care delivered by the right person. More money was needed for technology and staff but investing in preventing sight loss would save money in the long term. That could mean imaging linked through to ophthalmology departments allowing instant, remote expert advice rather than referral. Intraocular injections, more prescribing and cataract follow up were all within the skills of suitably qualified optometrists working in the community.
Speaking exclusively to Optician after the event, Prof Chang said remote working methods have long been available but the pandemic generated a greater need. ‘We created the Covid Urgent Eye Service (Cues) and that was a way for opticians to communicate with hospital ophthalmologists to provide history and pictures of what the condition was like, then we could provide advice.’ He said, within the NHS, a range of initiatives were being developed to reduce the need for hospital visits across a range of disciplines and put more onus on patients to understand when they need to seek hospital services.
‘There are 14,000 optometrists in the country that could help out with this,’ said Edmonds. ‘While some are within core competencies there were a range of higher qualifications and certificates, which currently existed, that were available.’ He described a five-step ladder: ‘Core competencies, WOPEC, prof cert, higher qual, IP. As we get closer to ophthalmology there will be certain pathways that need each of those steps.’ He said agreement of how that should be done was getting closer. Tackling the problem would require big funding and more people. The good news, said Prof Chang, is that in optometry the workforce was already there but it needed to engage in further qualifications more. In ophthalmology there needed to be a doubling in the number of ophthalmologists, he explained. Overall the increase in staff needed was ‘a factor of four’, said Prof Chang.
The hard part is making it happen. At the moment anything up to 30% of CCGs have not adopted Cues, demonstrating the difficulty in national action, said Edmonds. He and Prof Chang are philosophical about how hard getting things done will be, and admitted it is not in their gift. ‘Local adoption is still a challenge,’ said Edmonds, ‘but in Scotland, which has central control, more progress has been made. Prof Chang hoped the creation of regional Integrated Care Systems was drawing more agencies in. He said change was happening. ‘We’ve worked very hard with the College of Optometrists and Locsu and we have released a joint vision statement between the two for the first time.’
Edmonds agreed and says one of the positives of the pandemic has been closer working. ‘The two Colleges are working much closer together because we are all trying to solve a common problem. We all agree that the problem is exponentially growing and needs to be resolved in a different way.’