Provision of eye care: Commissioning change
Authors: Tarun Sharma, Richard Wormald, Wendy Franks
Journal: Journal of the Royal Society of Medicine (2008)

On 28 August 2007 Health Minister Dawn Pimarolo announced that independent prescribing for optometrists for a wider range of eye diseases will come into effect in 2008, potentially enhancing their role in managing acute and chronic eye disease.

A recent article in Which? magazine critical of the quality of eye tests attracted national press coverage. Almost half of eye examinations were graded as poor or very poor quality based on an assessment by trainee optometrists acting as clients during 39 sight tests performed in randomly sampled practices throughout UK. Last year, 10.2 million NHS eye tests funded by Primary Care Trusts were performed in England.1,2 The methodology of the survey could be criticized but the results do beg the question to commissioners and providers of eye services: how can high-quality, cost-effective eye care be delivered?

For providing a full sight test including a spectacle prescription, optometrists are paid a fee of £18.50.3 The true cost of providing the test in commercial practice is at least twice this and is subsidized by a considerable mark up on the cost of spectacles.2

From April 2006 optometrists in Scotland have been able to claim £36 for an eye examination without a spectacle test and £21 for any follow up visits. In England, the 2006 General Optical Services Review did not copy the Scottish decision and left the sight test fee unchanged, implying that there was no new money for eye care.4

Large optometry chains are replacing privately-owned individual practices in many areas and the uptake of refractive surgery and ‘over-the-counter’ reading spectacles reduces individual optometrists' income. In some parts of the country there is an oversupply of optometry graduates and jobs are hard to find.

Optometrists (ophthalmic opticians) are the principal providers of eye care in the community and can prescribe for correction of refractive error. Dispensing opticians make and sell spectacles but cannot prescribe, although they can dispense contact lenses. Optometrists undertake a three-year university degree course and one year pre-registration practice. With additional training they can prescribe from a limited formulary for common eye diseases. The British College of Optometrists provides post-graduate training in the detection and management of common eye diseases. Ninety percent of all cases of glaucoma, the second most common cause of irreversible blindness in the UK, referred to the hospital eye service are detected by optometrists and many are good at it.5 Referrals to the hospital eye service for glaucoma in one study had a positive predictive value of 0.46, which for a condition of low prevalence is quite good.6

Public perception is not uniform in understanding the eye health function of the sight test. The fact that tests are not free at the point of access (except for those exempt) and the concern over the high cost of spectacles which they fear they may be obliged to buy are important factors. This was highlighted by a recent RNIB survey on attitudes to sight tests7 which lead to inequity and steep social gradients in risk of sight loss.

Eye problems account for 1.5% of visits to General Practitioners8 and 9% of all hospital outpatient visits.9 Compared to optometrists, GPs have little formal training in eye care except in the unusual case of having developed a special interest. Meanwhile the hospital eye service struggles to meet the new NHS target of an 18-week pathway from referral to completion of treatment. Follow-up appointments for chronic problems may be postponed so that such targets can be met. Many staff grade and associate specialists are coming to retirement age and are proving hard to replace. Modernizing Medical Careers has rightly removed trainee ophthalmologists from many departments with large service commitments but few training opportunities. Optometrists are already working in extended roles in glaucoma clinics in the hospital eye service.

There is a valuable opportunity here to reconsider provision and commissioning of eye care and perhaps make cost savings without destabilizing the hospital eye service. An integrated eye care service in the NHS should provide the first contact care for all eye conditions and provide follow-up, preventive and rehabilitative care for selected conditions.10,11 Providing eye clinics within General Practice premises would remove one barrier to access for care. People on low incomes who are not eligible for free sight tests are deterred from attending commercial optometry practices and serious eye disease goes undetected.7 Optometrists employed on a sessional basis could provide primary eye care and follow up of chronic conditions, particularly glaucoma, in General Practices.

Independent prescribing for optometrists could mark a new and better era in the provision of eye care. The article in Which? is a reminder that quality assurance is essential. Standards alone are not sufficient. The Royal College of Ophthalmology and British College of Optometry are in agreement that ophthalmologists will need to assist in training and appraising optometrists providing primary eye care and this will need to be reflected in their job plans. Contracts between Hospital Trusts and Commissioners need to look at the total package of eye care provision for their community and move towards better integration of primary and secondary eye care.