From 1 April 2023, some ICBs will assume responsibility for general ophthalmic services along with pharmaceutical and dental care. At first, it will only be those ICBs that NHS England deems ready but, in time, all of them will take on these services. It is a chance to redesign eye care, and member of DHSC advisory Eye Health Forum, David Hewlett takes a look at how it might work.
With ophthalmology pressures and eye care need increasing, the establishment of ICBs and ICSs provides the ideal opportunity to address these challenges sustainably. It is a chance to reboot the eye care system across England with greater emphasis on prevention and early intervention.
With trusts working in collaboratives to Getting It Right First Time (GiRFT) principles, new opportunities to manage significant numbers of outpatients in primary eye care, and local authorities focusing on school screening, all the necessary tools for change are now at hand.
Most sight-threatening eye pathology is age-related, and the need will continue to rise as the population ages. It is forecast that by 2030, without intervention, there will be 9 million ophthalmology outpatients a year, including 1.8 million for glaucoma alone.
The good news is that most of this risk can be managed with early diagnosis and treatment. But to do that, we need to transform the outpatient model of care as set out in the NHS Long-Term Plan.
A conservative estimate is that at least 30% of ophthalmology outpatients could be seen and managed closer to home in primary care in a sustainable way.
National sight-testing and case finding
The national sight-testing and case-finding service – General Ophthalmic Services (GOS) – will continue to have nationally agreed GOS contracts, fees and grants. These remain the most efficient way of arranging this high-quality, standardised service for the whole population at the lowest possible transaction cost to the NHS.
GOS makes up Levels 1 (fixed practice) and 2 (mobile, domiciliary) of the national Primary Ophthalmic Services (POS) Framework (Table 1). GOS sees some 13 million NHS patients annually. A further 7 million working-age adults self-fund their sight tests but also become NHS patients if they need referral.
Although ICBs will manage GOS contracts in future, much of the administrative work has now transferred to Primary Care Services England (claims, payments and performer listing) and the NHS Business Services Authority (contracts). This, in turn, means ICBs can focus more on the efficient provision of enhanced primary eye care services to prevent blindness and meet needs locally.
Enhanced primary eye care
The vehicle for change at an ICB level is locally commissioned enhanced primary eye care services (Level 3 of the national POS Framework). These services can help prevent referrals, retain more patients in primary eye care for treatment, monitoring and discharge, and provide further options for co-management out of hospital. Unlike sight-testing, these services operate under the NHS Standard Contract and the new Provider Selection Regime (Table 1).
As hospital capacity is limited by workforce and estate constraints, it makes sense for ICBs to focus on utilising the available skill and facilities in primary eye care in this way.
Eye care redesign
CCGs were too small to commission enhanced primary eye care services effectively or equitably across areas. ICBs can fix that by commissioning services at pan-ICB and multiple ICB levels as part of strategic change. Primary eye care should be the NHS’s first point of contact, treatment and discharge for most eye health issues and achieving this – and getting a better primary/secondary care balance – should be part of local strategies and plans.
IT connectivity also plays a role. NHS England is looking urgently at IT connectivity options to meet the September 2023 target date for ophthalmology referrals.
So, ICBs now have all the tools to achieve effective eye care change and eliminate avoidable blindness caused by NHS waits and capacity challenges in affordable and sustainable ways.
Through these columns, we look forward to engaging with ICB and ICS leaders to deliver these changes and welcome feedback.
David Hewlett is Eye Health Forum member, at the Department of Health and Social Care. He can be contacted at: [email protected]