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Eye care in the system: how delegation of eye care services is working in ICBs

Eye care in the system: how delegation of eye care services is working in ICBs
By Kathy Oxtoby
25 March 2024

Almost a year since taking over commissioning of ophthalmic services, what are ICBs’ priorities, and what do eye care professionals think of ICBs’ performance so far? Kathy Oxtoby explores the issues

Having healthy vision is something many of us take for granted – until there is a problem. And when problems occur, they can have an impact beyond eyesight.

‘Eyesight is precious for living life, whether education, employment or enjoyment,’ says optometrist Dharmesh Patel, chief executive of Primary Eyecare Services, a not for profit lead provider of eye care services.

‘Poor eyesight can impact on people’s level of dependence, lead to falls – a cause of hospital admissions – and mortality problems,’ Mr Patel says.

The immense impact of eye issues on people’s lives is reflected in the sheer scale of eye care services in England. Ophthalmology is the largest outpatient specialty in the NHS, with more than 8 million appointments in 2022-2023.

However, the vast majority of NHS ophthalmology services are facing ‘significant capacity pressures’, according to a census report by the Royal College of Ophthalmologists, with more than three quarters (76%) of units not having enough consultants to meet current patient demand and over half (52%) finding it more difficult to recruit consultants.

Ms Bushra Mushtaq is a consultant ophthalmologist with a special interest in medical retina, Birmingham and Midland Eye Centre (BMEC), Sandwell and West Birmingham NHS Trust, and chair of the UK Ophthalmology Alliance (UKOA), a membership group of NHS ophthalmology providers and stakeholders. She says a major issue for the specialty is the backlog of more than 600,000 new patients waiting to be seen by ophthalmology services in England. Added to this is a backlog of more than 600,000 patients requiring eye surgery, she says.

Pressures on ophthalmology services look set to increase. The majority of sight-threatening disease is age-related, and so need is rising as the population ages.

Optometry: ‘A viable solution to cut the eye care backlog’

Primary care optometry, and extended services in the community have ‘quite rightly been recognised as the appropriate and viable solution to cut the eye care backlog’, says Dr Peter Hampson, clinical and professional director for the Association of Optometrists (AOP).

‘Optometrists are highly trained eye specialists who are already providing many of the extended services that are needed to reduce pressure on hospital eye departments, A&E and also GPs,’ he says.

‘The evidence shows us that schemes such as the Minor Eye Conditions Service (MECs), Community Urgent Eye Care Service (CUES) as well as glaucoma referral refinement, can cut the number of patients going into secondary care by as much as half, sometimes more.

‘In addition, the monitoring of stable chronic conditions can also help to move patients out of secondary care to further release capacity,’ says Dr Hampson.

But while optometry may be a solution to the eye care back log, the profession also faces its own challenges.

Funding through the NHS General Ophthalmic Services (GOS) contract to provide the NHS sight test remains a challenge for optometrists on the high street, says Mr Patel. ‘Having insufficient funding, and not keeping pace with the costs of delivering sight tests is a real challenge, and we need to think about how we fund the sight test effectively,’ he says.

Karen Gennard is an optometrist in independent community practice working for Norville Independent Eyecare in Cheltenham, Gloucestershire, and AOP councillor for south west England. She says the GOS contract ‘is outdated and in need of some reform’.

Outside of the GOS contract, there are also additional commissioned services, which are different across the country. ‘So, you have a contract that is national, and then there are commissioned services, which are variable,’ she says. For patients, it’s a ‘post code lottery’ as to what commissioned services will be available, while for optometrists, this variability also adds an extra layer of administration in terms of claiming payments for different schemes, she says. 

Alan Hawrami is an optometrist independent prescriber and glaucoma specialist and director of two optometry practices that deliver community ophthalmology and primary care optometry – Osborne Harle in Tonbridge and Kent Eye Care in Aylesford. A member of an optometrist independent prescribing group, he says ‘acceptable remuneration’ for services is an issue for the profession.

‘Many optometry practices don’t take on certain services because they will lose money, compared to seeing patients for sight tests,’ he says. He highlights how optometry practices are also businesses that require premises, staff, and equipment. If a service isn’t commissioned for an appropriate fee ‘the business may not be able to survive’, he says.

Digital connectivity  

Digital connectivity is also an issue, says Mr Patel. ‘Ultimately, optometry is responsible for the vast majority of referrals for further care in hospital for ophthalmology services. However, there is a substantial lack of digital connectivity that enables that to happen in an efficient way, that is timely and patient centric.’

He says that optometry is ‘not connected into the NHS digital architecture’ and that, for example, it does not, as a whole, have a seamless way of making electronic referrals from optometry to hospitals that avoids the general practitioner’.

There is also not the opportunity for digital feedback and communication between optometrists and ophthalmologists. ‘While there are some pockets of good work, we do not have that consistently across the country,’ says Mr Patel.

To help manage demand, he says optometrists and ophthalmologists need to be able to work together in a ‘streamlined digital way that is efficient, and we don’t have the funding/investment and implementation of that at a national level’.

Despite the challenges facing optometry, the profession is well placed to address the eye care patient backlog. However, Dr Hampson says that while the evidence ‘all points to optometry having the workforce, skills and equipment needed to deliver more clinically, and indeed we see this working successfully in Scotland and now in Wales, the political will and appetite for a national roll-out of services is still lacking’.

‘This is reflected in the inconsistent way that services are commissioned by ICBs and variability between counties,’ he says.    

ICBs: commissioning responsibility for ophthalmic services

It is almost a year since ICBs became responsible for commissioning ophthalmic services, as well as pharmacy and dentistry (POD). The move, on 1 April 2023, was part of a series of commissioning reforms set out in the Health and Social Care Act 2022. Under the act, NHS England still has overall accountability for these primary care functions. The aim of managing POD at a system level is to enable local decision making and a more joined-up approach to delivering services.

Sarah Walter, director of the ICS Network at the NHS Confederation, says ICSs ‘want to redesign pathways to keep people healthy and improve health outcomes’. ‘In optometry, this means thinking more about improving sight from public health through to primary optometry and onto specialised services,’ she says. ‘The delegation of primary optometry commissioning and, shortly, some specialised services, will give ICBs the resources and responsibility for organising care right across eye health pathways.’

Ms Walter says there are already ‘positive examples of proactive collaboration with commissioners and primary care providers in some areas around optometry’. ‘To be most effective, this can and should be encouraged and continued in close collaboration with primary care providers, where much eye health expertise sits,’ she says.

Since ICBs have taken over commissioning, Ms Mushtaq says she has seen ‘a very positive change’. ‘One of the major changes is that we know who to approach to solve problems – we have a name within the Birmingham and Solihull ICB who we can contact to raise issues. It’s a very good start.’

Mr Hawrami says he has found his ICB – NHS Kent and Medway – to be ‘more proactive at getting services commissioned compared to the CCG system’. ‘I’ve also found it’s much easier to get in contact with the relevant people at the ICB,’ he says.  ‘What’s working well is their openness to listen to community clinicians, and their desire to action any queries and issues.’

Since taking on the responsibility for NHS primary eye care, ICBs have been commissioning providers like Primary Eyecare Serviceswhich is a lead provider of NHS funded eye care services across large parts of England. 

‘What we do as a lead provider is contract for primary and community eye care services – in the enhanced services category – and work together with optometry practices to deliver that,’ says Mr Patel, chief executive of Primary Eyecare Services.

The organisation is a lead provider for optometry services across 29 ICBs, and works with a network of over 2,350 optometry practices, and this year will have supported more than 700,000 patients. 

From a provider’s perspective, he says the overarching picture for ICBs, given the amount of priorities and pressures they are facing, continues to be challenging across the country.  

Personnel changes at ICBs – which mean a new person has to learn the nuances of ophthalmology, or a specific contract for example – have been an issue during this first year, he says.  However, he says there are ‘lots of good examples where eye care is considered a priority, and we have close working relationships with ICBs, and in those systems we’re seeing real progress’.

‘And it’s great to see some ICBs looking at their eye care transformation plans – reviewing their services, looking at what’s working really well, and what they need to accelerate,’ he says. ‘And that’s what we need every ICB to be doing when it comes to eye care services across optometry and ophthalmology, to make sure they have a really clear plan across the system.’

NHS Humber and North Yorkshire ICB: Relationship building and new ways of working

Eye care issues facing Humber and North Yorkshire, include ‘backlogs in follow-up appointments with increased time periods between appointments for glaucoma and medical retina, which could lead to preventable sight loss’, says Nizz Sabir, NHS Humber and North Yorkshire ICB clinical lead for optometry.

Workforce shortages in ophthalmology and optometry mean ‘we are heavily reliant on a locum workforce’, says Mr Sabir. Optical practices’ estates and skills in primary care are under-utilised due to lack of funding for GOS, and there is a lack of services commissioned beyond GOS – ‘this creates avoidable referrals’, he says.

Inequality of referral routes into secondary care is also an issue. ‘Some areas are still referring via GP – who are already under huge pressure and facilitating direct referrals. In North and North East Lincolnshire, for example, we are referring direct via With this direct referral mechanism, optometry can ease the pressure on GPs and expedite care.’ 

An Eye Care Steering Group is set up across the Humber and North Yorkshire area and is firstly concentrating on secondary care sites and collaboration between trusts. ‘A Local Optometry Network is being set up to help have a framework to work towards some of these issues. We aim to work collaboratively with a range of stakeholders to improve our populations eye health and care outcomes,’ says Mr Sabir.

Community optometry referral refinement schemes are there for the public to access for any minor eye conditions or concerns in almost each area in Humber and North Yorkshire, although commissioning models may vary, he says.

A collaboration between pharmacy and optometry through the primary care collaborative is in its second stage of piloting. ‘This is to help identify gaps in the public accessing eye care and who may be at risk of hypertension, as well as reducing referrals to general practice and referring directly to the pharmacy,’ says Mr Sabir, and there has been ‘a large uptake’ of optical practices across Humber and North Yorkshire.

Mr Sabir is co-chairing the Humber and North Yorkshire Eye Care Steering Group with an ophthalmologist. ‘This is allowing for relationship building and new ways of working. It is developing understanding and opportunities to work in a better way for the future,’ he says.

NHS Greater Manchester ICB: Close collaborative working between primary eye care providers and commissioners

The ICB’s priorities for eye care include reducing referrals into ophthalmology that could be managed out of hospital, as well as supporting the transfer of care out of hospital where safe to do so, says Julia Maiden, optometrist and optical lead, Optometry Provider Board, NHS Greater Manchester ICB.

Both the CUES and the glaucoma referral refinement service have shown to be ‘effective and safe’, and have now been scaled up to cover the whole of Greater Manchester to ‘ensure equity of provision to our patients’, says Ms Maiden.

And the Primary Eyecare Glaucoma Service (PEGS) pilot ‘utilises a network of optometry practices to monitor patients with stable glaucoma, which has been shown to be both safe and convenient for patients’, she says.

Close collaborative working between primary eye care providers and commissioners has been key, says Ms Maiden, and NHS GM has a dedicated contract manager to support the eye care contract and commissioners in the ten GM place-based boroughs.

Funding remains ‘a challenge’, and there is ‘a need to continuously review tariffs for primary and community contracts just as there are with acute contracts, to ensure ongoing sustainability’, says Ms Maiden. This is something NHS GM now carries out for primary and community eye care contracts.  

The Optometry Excellence programme has established four workstreams to support continuous improvement within optometry, says Ms Maiden. The rescue and resilience workstream focuses on health and wellbeing and workforce development. Practical support is about supporting practices and practitioners who provide service pathways that have been developed as part of the Elective Reform and Recovery Programme, and reducing health inequalities through the Pride in Practice and the people with learning disabilities Easy Eyecare Service. The optometry referrals improvement programme will analyse trends and identify inequalities, and provide practitioners with the ability to self-review their referral habits to enable personal development and quality improvement. And sustainability will look at both green and financial sustainability of the optometry sector.

‘We have a long-standing collaborative working relationship’ with NHS Greater Manchester ICB, says Dharmesh Patel. The ICB is demonstrating ‘how you can better utilise optometry, and how you can engage with optometry alongside its other primary care colleagues’. ‘It’s that collaborative working approach which is critical to a sustainable primary care optometry model, and ultimately collectively supporting the demands and needs of the population’s eye care,’ he says.

NHS Gloucestershire ICB: Tackling health inequalities

Gloucestershire has had an eye health clinical programme since 2015, and eye health has been a focus long before the POD delegation, says Kerry O’Hara, programme director for clinical programmes at the ICB.

‘Rather than just looking at one profession, one provider, one way of commissioning, we’re bringing together optometry and ophthalmology, both from the NHS and independent sector, along with patients and voluntary and charity organisations and looking at eye health in Gloucestershire,’ she says.

One area of focus is tackling health inequalities, and working with Vision Care for Homeless People (VCHP), along with optometry colleagues, the ICB has set up a weekly eye care clinic for homeless people, where they can access a free eye test and free spectacles.

The ICB is also working with RNIB to provide eye care liaison officers on care of the elderly wards.

Another focus area is digital transformation. ‘Often the only record optometrists hold for a patient is their own record. Even if they make a referral to the hospital, the outcome of that referral doesn’t go back to the optometrist, it goes to the GP,’ says Ms O’Hara.

Since 2023, in Gloucestershire, with patient consent, their ophthalmology data, including referrals and images, is shared with community optometrists. The system, OphthalSuite Community Ophthalmic Link, enables community optometrists to access patient’s eye health records quickly and securely. Patients are benefitting from better care in the community, less need to travel to a hospital, and the project is helping to prevent avoidable sight loss.

Optometrist Karen Gennard, who is a new clinic development manager at VCHP, says the VCHP clinic for homeless people in Gloucestershire is ‘trying to reduce some of the barriers to accessing healthcare’. ‘If somebody comes to see us and they are not eligible for GOS service, then the ICB will fund that,’ she says. The funding makes ‘a huge impact on that person who could not otherwise access eye care,’ she says.’

She says the community ophthalmic link has ‘completely changed how I work in practice’.  It enables optometrists ‘to see all the imaging in one place’ and it can ‘save unnecessary referrals back into the hospital’.

North East and North Cumbria ICB: Redesigning a more integrated patient pathway

With demand for eye care still increasing, ‘we will do more early intervention and prevention work, with primary care contractors helping to ease the pressure on hospital services’, says David Gallagher, executive area director at North East and North Cumbria ICB.

‘In the short term, our priority is to reduce waiting lists for hospital eye care,’ says Mr Gallagher. Looking further ahead, the ICB is redesigning a more integrated patient pathway to make better use of community optometrists and offer more joined-up care to patients. ‘It’s important to make sure that patients are only referred for hospital eye care if their needs cannot be met by suitable community-based services,’ he says.

‘Working with our Eye Care Alliance, which brings together commissioners, primary and secondary care, and clinical advisors, we will enable primary care contractors to widen the range of services they offer. By developing new standard ways of working, including guidance for self-care, we aim to reduce variation and create an end-to-end pathway,’ he says.

Other plans include ‘provision of sight tests and dispensing in special education settings, and work to identify opportunities for remote consultations, where this is helpful and clinically safe’, says Mr Gallagher.

NHS Black Country ICB: Dedicated eye care service for urgent assessment and treatment

People in the Black Country with sudden onset eye problems can access a dedicated eye care service for urgent assessment and treatment. The Community Urgent Eyecare Service (CUES) is a free NHS service for anyone who is experiencing emergency eye care problems and is registered with a GP in the Black Country.

Symptoms that can be treated by the service include red or painful eye or eyelids, and recent and sudden loss of vision. Adults and children can use the service, which is available via participating opticians across the Black Country, without the need for a GP referral. 

Sarb Basi, director of primary care for the ICB, says in most cases, ‘the CUES will be able to treat patients quickly and easily. And, if hospital treatment is needed, the service will arrange an emergency appointment with an eye specialist at a hospital – meaning that patients have access to the right care straightaway.’

In the Black Country, ‘there is a hugely talented workforce in primary care opticians who have the equipment and skills required to assess, diagnose and where necessary, treat eye problems’, he says. ‘The CUES is a great example of providing more efficient care closer to home by minimising delays and reducing the need for hospital visits.’

Future for ICBs and NHS eye care

Mr Patel says as ICBs are ‘still maturing and we don’t yet have sufficient inter-ICB sharing’. ‘But that sharing and learning is so critical,’ he says.

ICBs also need to ‘ensure that they are talking to all of primary care – recognising that primary care means community pharmacy, dentistry, general practice and optometry’, he says.

His wish list also includes ensuring that ‘we fully utilise optometry through locally commissioned services’, and that ‘the digital connectivity needs of the eye care pathway are addressed’.

While Mr Patel appreciates the challenges ICBs are facing, and that every aspect of healthcare needs due attention, ‘we can’t afford not to have attention on eye care’, he says. ‘Optometry can really help with their system pressures across urgent and emergency and elective care, and all we need them to do is engage with optometry representatives locally, and organisations like Primary Eyecare Services for help and support.’

Ms Gennard wants ICBs to ensure that commissioned services are ‘financially viable for practices, so that they do sign up to them and continue to use them’.

And she says ICBs need to ‘actively engage’ with their local optometrists. ‘It’s about having those good relationships with Local Optical Committees (LOCs) and with eye health networks, so that you’re bringing together everybody who is looking after eye care within the county’. ‘It all comes down to good communication, good systems, and good tech,’ she says.

Mr Hawrami would like ICBs to have more involvement with optometrists in the community – finding out about the skill sets that are available to them, such as the highly specialised glaucoma optometrist who can see a higher complexity of glaucoma patient.

Ms Mushtaq would like to see ‘flexible, sensitive commissioning pathways’, with commissioning focused on where there are bottle necks in care, and on supporting patients according to the severity of the eye condition – particularly those conditions where, without treatment, loss of sight may be irreversible.

Closer working relationships are needed between ophthalmology and primary care optometry services, she says. She would like to see leaders and decision makers in both primary and secondary care, along with ICBs, to ‘find ways that we can work together to solve eye care issues’.  And in particular, what is needed from these leaders and decision makers is to plan ‘a long-term strategy for eye care’, she says.  ‘It’s the right time – the connectivity is coming in, and the ICBs are willing and keen to have these conversations.’

‘We need to see decisive action to address the inequitable provision we’re seeing across the UK,’ says Dr Hampson.  ‘We’re facing an urgent situation within eye care, with as many as one in eleven people languishing on NHS waiting lists for a hospital eye appointment. Delays that literally can cost a patient’s sight and inconceivably, for conditions that are otherwise treatable.’   

He says the majority of these challenges can be attributed to the fact that unlike other UK nations, England does not have a national plan for eye care. ‘As a result we’ve ended up with a patchwork quilt of services across the UK, with patients in some areas going without as a result.’

As the AOP has set out in its Sight won’t wait campaign ‘this fundamentally comes down to three critical changes that need to happen to improve patient access’, says Dr Hampson. The AOP wants basic IT connectivity to be put in place between primary and secondary care to speed up patient referrals, the extension of the scope of community eye care services so more patients get the care they need, closer to home, and the widening of the prescribing powers of optometrists to alleviate pressure on GP services, hospital eye departments and A&E.

Dr Hampson says optometrists on the high street ‘have the premises, the equipment, and the clinical skills to deliver accessible, high-quality eye care’. ‘But to ensure optometry can provide the care patients need it will take the will and vision of ICBs to commission the services that are required, alongside a collaborative approach with their optometry partners.’

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