Service redesign in eyecare is needed – that much is clear. The reality, long identified by academic studies, is that sight loss is becoming more prevalent as the population ages.
As of earlier this year, over 632,000 people in England – one person in every hundred – were on waiting lists for NHS ophthalmology treatment, with 24,000 people waiting for over a year. In Wales, over 140,000 R1 patients are on waiting lists for outpatient ophthalmology appointments.
The long shadow of the COVID-19 pandemic is clearly felt in the scale of backlogs, but the roots of this crisis are much deeper and more structural. Even before the pandemic began to undermine outpatient activity, 440,000 people in England were waiting for NHS ophthalmology treatment. While in Wales, the figure waiting for ophthalmology outpatient appointments, in January 2020 was 118,801.
Adding to the problem is a shortfall in the ophthalmology workforce. The Royal College of Ophthalmologists’ recent workforce census found that only 24% of eye units had sufficient numbers of consultants to meet demand, and just 22% had enough SAS doctors.
It is clear that we need more ophthalmologists to meet this rising demand. But it takes 10 years or more to train an ophthalmologist so, even if training capacity increases overnight, the workforce will remain under pressure for years to come. The only solution available in the short term is a service redesign in eyecare to make the most efficient use of the existing workforce.
The good news is that such redesign is possible, enabled by new technologies, such Optos’ ultra-widefield (UWF) retinal imaging devices. These can deliver 200° single captures of the retina in less than half a second, improving both the accuracy and speed of screening, diagnostics and ongoing monitoring.
A shared care model
It was my time as a patient at the University Hospital of Wales (UHW) that led me to explore how a redesign could work. In just 20 minutes, my life changed when I experienced a vein and artery occlusion, losing sight in my right eye. As a result, I designed and implemented a shared care model for eye care services, to better join up community optometry and hospital services.
Under normal circumstances, embedding such a model would have taken years. But then COVID-19 came along and, in April 2020, the Welsh Government closed all non-emergency outpatients’ services. Overnight, radical service redesign in eyecare became a necessity.
Within four weeks, the eye care team at UHW used the shared care model to:
- Mobilise four independent prescribing optometrists to deliver 80% of emergency eye care clinic activity outside hospital.
- Connect five optometry practices safely and securely to the Cardiff and Vale University Health Board network to support new and follow-up glaucoma patients through virtual ophthalmology clinics.
- Enable consultants to review patients from home.
None of this would have been possible without the right technology in place to deliver virtual clinics, connect patients with clinicians or capture, share and analyse patient images and records. For example, high quality UWF retinal images can be shared easily with consultants working remotely. This then releases hospital capacity to treat the most complex patients.
Proof of concept
Our experiences at UHW during the pandemic have served as proof of concept for these new ways of working. Our shared care model is effective in reducing demand on consultant ophthalmologists and their teams. Instead, we are relying on optometrists to deliver more care outside hospital.
But as we focus on addressing record waiting lists, we must ensure optometry has the workforce and resources to deliver post-pandemic recovery.
NHS Wales is taking steps to help meet this need, reforming contracts to enable suitably qualified optometrists to treat patients locally in primary care and developing a new MSc Optometry curriculum.
For my part, I am proud to have worked with Cardiff University’s School of Optometry and Vision Science to establish the NHS Wales University Eye Care Centre (NWUECC), to train optometrists from across Wales in both the Higher Certificate in Glaucoma and Medical Retina. A second such centre is now being launched in North Wales.
New technology
As well as developing the workforce, the NHS in Wales is investing in the technology needed to deliver these new models of care.
In 2022, the Welsh Government procured 18 Optos Monaco imaging cameras to be installed in primary care optometry practices. To ensure that clinicians understand how to make the most of these tools, two Monaco units have been installed in the NWUECC for use in a weekly clinic. This both exposes clinicians to the technology, and improves patient care; with the right support from a medical illustration photographer, patients can be assessed in a single visit. An added benefit is that this reduces the “did not attend” rate.
There is a strong body of clinical evidence which demonstrates the benefits of UWF retinal imaging. One 2021 study in a US academic ophthalmology department found that implementing UWF imaging alongside optimised patient flows delivered a reduction in appointment times of almost 30% while another US study, found that implementing UWF imaging delivered a 4.4% increase in patient numbers in year one and a 7% increase in year two.
Our experiences at UHW support these findings.
Ultimately, to tackle the crisis in NHS ophthalmology, we need to do things differently. UWF retinal imaging could play a key role in addressing the eye care crisis if it was rolled out as part of wider service redesign and implemented by an upskilled primary care workforce.
Investing in this technology would allay a key concern of the eye care workforce – that is, a lack of investment in infrastructure is undermining patient care. And, at a time when overall NHS satisfaction is at its lowest on record, rolling out more advanced, less burdensome exams would be well received by patients.
