The shape of primary eye care: Where are we now and where do we need to get to?

The Office for National Statistics (ONS) has shown that the UK population continues to age. The median age is now 40 and 18% of the population is aged over 65(1).

We also know that hospital eye departments are bursting at the seams. In 2015-16 ophthalmology was a very close 2nd for outpatient attendances with over 7 million attendances(2). Compare this with a total outpatient attendance of 83 million for NHS patients. Of-course this probably doesn’t account for local community commissioned activity and so the total activity is likely even higher! Follow- up patients are losing vision(3). A BOSU study(3) showed 169 patients reported of preventable loss of vision. Of these, 132 experienced permanent deterioration of vision along with 15 unplanned surgical procedures and six emergency hospital admissions. 42 patients were registered as Severely Sight Impaired or Sight Impaired. The reasons for this are many and probably stem around the way we set hospital targets – namely the 18 week wait from referral to treatment which may lead to precedence over these patients from those with chronic disease needing follow up treatment. In either case, this topic probably deserves a section of its own and we are at risk of digressing. In summary, as a population we are getting older, patients with ophthalmic disease are growing and hospitals are struggling to cope. Even worse than this is that patients are losing vision irreversibly and this is preventable.

Optometrists are a capable and motivated workforce that can help meet this demand. Solutions have been put forward by way of enhanced optometric services. We have Minor Eye Conditions (MECS and PEARS), Glaucoma Referral Refinement, Community referral refinement, Glaucoma monitoring, AMD community schemes, Cataract schemes etc. These schemes, however, are not homogenous nationwide and have a poor evidence base for skills needed for participation. The cost effectiveness appears best for glaucoma and the added value for the other schemes is questionable. The biggest problem with these fragmented approaches is that they are merely stop-gaps and not a long-term solution to address the current problem. What we need is a homogenous, well defined ophthalmic pathway that involves every optometrist. The roles need to be clearly defined and management pathways clearly established.

To help, we need to share ophthalmic records and have improved avenues for communication between primary and secondary care. How many times have you wished the ophthalmologist had copied you into correspondence to help your decision making? Or, had the opportunity to speak to secondary care rather than having to refer due to a lack of available information?

Perhaps some of these views are contentious, but are my views nonetheless.

Some great ongoing projects such as the Educational Strategic Review(4) at the General Optical Council and the Ophthalmology Common Clinical Competency Framework (OCCCF)(5) at the Royal College of Ophthalmologists are much needed additions to help fix this problem. These projects will set foundations to design and homogenise patient pathways for shared care working.

The future in the optical sector is being shaped today. The foresight report (6) highlighted the tremendous change we may expect over the next 20 years. It demonstrated how technology may impact upon the core work of today’s optometrist. Perhaps, refraction will become app based or auto-refraction will become the norm. 3D printing may allow people to create their own frames and on-line glazing will be a relatively cheap option. De-regulation of sight testing is a real threat.

It would appear, therefore, there is common ground between secondary care and primary care eye services. Optometrists will not only be asked to share the burden of chronic ophthalmic disease but will be forced to do so by the changing face of optical practice.

Many optometrists already work in conjunction with secondary care. I have the pleasure of working with some great optometrists in shared care clinics almost every day. However, in order to meet the demands outlined above, we will be required to help every optometrist to develop their scope of practice and encourage a drastic re-design of ophthalmic service delivery. We will also require greater engagement and avenues of communication between primary and secondary care eye services.

These are the biggest challenges facing the optical world today. Getting this wrong could lead to dismantling of the optical world as we know it and lead to regression rather than progression of the profession.


1. Population estimates for UK, England and Wales, Scotland and Northern Ireland - Office for National Statistics [Internet]. [cited 2018 Feb 23]. Available from:

2. hosp-epis-stat-outp-summ-repo-2015-16-rep.pdf.

3. Foot B, MacEwen C. Surveillance of sight loss due to delay in ophthalmic treatment or review: frequency, cause and outcome. Eye. 2017 May;31(5):771.

4. Education Strategic Review [Internet]. [cited 2018 Feb 23]. Available from:

5. Opthalmologists TRC of. The Royal College of Ophthalmologists receives new funding to support eye health workforce development [Internet]. [cited 2018 Feb 23]. Available from:

6. foresightfull-reportwebsps.pdf [Internet]. [cited 2018 Feb 23]. Available from:

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