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Building a case for an optimal glaucoma pathway

In January 2021, 604,4012 people were waiting for a first treatment in ophthalmology, 230,872 have waited more than 18 weeks3 and 48,703 have waited more than a year4. How can an optimal glaucoma pathway be achieved and what would the outcomes be for all involved?

Back in January 2019, Richard Whittington, then assistant director of commissioning, now chief executive of Local Optical Committee Support Unit, wrote a blog for the NHS England (NHSE) website. Entitled Creating a Community of Care on Eye Health,1 it made interesting reading then and resonates as firmly now during these challenging times for the NHS. 

Richard’s central point was that optical professionals are a key asset in protecting and transforming the health outcomes of citizens; assessing someone’s ocular function and acuity can discover more than just a need for spectacles. Hitherto undiagnosed disease can be detected, and an earlier intervention will bring better outcomes. Certainly, now is the time to ensure the experts are given a platform to drive change across a whole system of care.

Despite this, optical clinicians and their teams are often neglected in the scheme of multi-disciplinary team working and fail to be recognised as front-line healthcare professionals (HCPs); a phenomenon experienced by other groups of HCPs.

Optical professionals, working in the community, do so largely on the same streets as another health and social asset that has often faced status issues. Community pharmacy, just as optical professionals do more than sell spectacles, does more than dispense pills. Yet, while it has had to struggle to assert its place, it is now instrumental in the system leadership that is demanded as a result of the NHS Long Term Plan and the spawning of integrated care systems (ICSs). In London, Local Pharmaceutical Committees (LPCs) have driven forward a community pharmacy strategy, which determines a new service offer5. There is significant value to be drawn down through an integrated care pathway, where community optometrists are working hand-in-glove with consultant ophthalmologists. However, relationships between any co-professionals only prosper where dialogue is supported that drives parity of esteem across all health professionals involved in the achieving of better outcomes for patients.

“There is significant value to be drawn down through an integrated care pathway, where community optometrists are working hand-in-glove with consultant ophthalmologists”

The recently published Government White Paper, Integration and innovation: working together to improve health and social care for all6, is a ‘blueprint’ for: “stripping away unnecessary legislative bureaucracy, empowering local leaders and services and tackling health inequalities.”7

This builds on the NHS’s Long Term Plan8 proposals and is set to accelerate the rate of integration across the NHS, making the case – as stated in the White Paper: “…for joining up and integrating care around people rather than around institutional silos – care that focuses not just on treating particular conditions, but also on lifestyles, on healthy behaviours, prevention and helping people live more independent lives for longer.

We need the different parts of our health and care system to work together to provide high quality health and care, so that we live longer, healthier, active and more independent lives.”

This person-centred focus extends its lens into the working approaches and arrangements for, and between, HCPs. Dividing lines being painted out of the picture, walls coming down and silos being opened up; admirable and much needed actions but inter-health professional status has to be assured too. True shared decision making on how to plan, build, deliver and measure optimum care requires all the care professionals involved to view each other as equals.

Start at the beginning
What are the implications and pointers in this for the optical health community? Finding a common cause is a good starting point. In the current climate of COVID-19 restrictions, the associated impacts on health and wellbeing in the population, and the consequences for our health systems, looking at a care pathway that is under strain is a good jumping-off point.

Glaucoma as a group of eye conditions is one of the most common causes of blindness worldwide9. In the UK about 2% of the population over 40 have the condition and by 2035, the number of people living with glaucoma in the UK is expected to increase by 44%.10

While much of the diagnosis of glaucoma in the pathway resides in secondary care, there is a growing consensus that more of the risk stratification and management needs to be done in the community. For many years there have been designs to expand the provision of care in local communities. The NHS Long Term Plan set objectives for that with out-of-hospital models and an overarching plan to avoid admissions.

Issues that were once barriers to getting services out of Trusts and into the community, have started to fall. It provides an opportunity for optical clinicians and their teams to unite around an issue and assert their place in a glaucoma optimal care pathway.

Though the barriers might be lower, culture, custom and practice can be stubborn agents to remove. However, things have shifted. The financial regime has been turned on its head, block contracts are altering the motivations of hospital leaders. COVID-19 has necessitated reduced hospital footfalls and many of those resistant to change, have been persuaded to align. The development of ICSs has accelerated joined up working. An important emerging development is the place of accountability; incentive and sanction are now at system level.

All this shows good prevailing conditions to steer optimal care through the community. Given that waiting lists for glaucoma treatment might very well be keeping a lot of Trust CEOs awake at night, this presents another opportunity to state the case for community care.

“We need an optimal care pathway to collect the data to help address unmet need and inequalities through interventions that are based on shared decision making between patients and HCPs alike”

It is clear that there is a powerful body of evidence for galvanising the strength of offer in community optometry in delivering within an optimal glaucoma care pathway. From diagnosis to follow-up care, care in community settings will provide a better experience for patients, strengthen the role of community optical clinicians and better serve the objectives of integrated care.

The recent NHSX allocation of £8.5m funding across England’s seven NHS regions11 for technologies that allow hospital ophthalmologists to access records, referrals and diagnostic images from high street optometrists, will bring community optometrists within real-time reach of secondary care clinicians and support the sharing of diagnostic images and streamline referrals. This will allow optometrists to consult with clinicians in real-time, share diagnostic images, and refer patients to hospital, forming part of a much-needed infrastructure for optimising integrated glaucoma care in the community.

While there is not a register of people who might be good candidates for better outcomes from an optimal care pathway to support unmet need, the focus must remain on not precipitating inequalities in prescribing of glaucoma medications. We need an optimal care pathway to collect the data to help address unmet need and inequalities through interventions that are based on shared decision making between patients and HCPs alike. Pharma companies like AbbVie are starting to engage with these challenges and see themselves as potential partners of the NHS in a purposive approach to addressing these kinds of challenges.

Changes in the NHS landscape, the delivery of care and the COVID-19 pandemic have taught many things to all those engaged in providing quality patient care. A clear opportunity to act exists; everyone needs to change their mind-set and demonstrate a commitment to work in partnership across the whole healthcare system. Adopting shared goals that move us away from silo leadership and thinking and deliver more positive outcomes rather than just more barriers.


[1] NHSE Blog: Creating a community of care on eye health. Richard Whittington https://www.england.nhs.uk/blog/creating-a-community-of-care-on-eye-health/

[2,3,4] NHS England https://tinyurl.com/rttdataJan21

[5] London Community Pharmacy: Our offer to London Pharmacy Strategy 2020 https://psnc.org.uk/pharmacylondon/wp-content/uploads/sites/112/2020/09/Offer-to-London.pdf

[6] Government White Paper, Integration and innovation: working together to improve health and social care for all https://www.gov.uk/government/publications/working-together-to-improve-health-and-social-care-for-all

[7] https://www.gov.uk/government/news/blueprint-launched-for-nhs-and-social-care-reform-following–pandemic

[8] NHSE Long Term Plan https://www.longtermplan.nhs.uk/


[10] Increase in incidence of Glaucoma to 2035 https://glaucoma.uk/about-glaucoma/

[11] https://www.nhsx.nhs.uk/blogs/transforming-eye-care-services-through-better-connectivity/

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Mike Proctor
Mike Proctor is Non-Executive Chair at Conclusio


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