Written evidence submitted by the Optical Confederation and Local Optical Committee Support Unit [DEV 048]

The Optical Confederation represents the 12,000 optometrists, 6,000 dispensing opticians, 7,000 optical businesses and 45,000 ancillary staff in the UK, who provide high quality and accessible eye care services to the whole population. The Optical Confederation also represents manufacturers, distributors and importers. As a Confederation we work with others to improve eye health for the public good.

Local Optical Committee Support Unit (LOCSU) provides quality, practical support to Local and Regional Optical Committees (LOCs) in England to help them to develop, negotiate and implement local objectives in respect of primary ophthalmic services.

Response
As eye health professionals and providers we fully support the NHS, the aims of NHS England’s Five Year Forward View and planning guidance and the possibilities opened up by local working on new models of care.  However we are also concerned that this may result yet again in too much focus, and time and effort, spent on structures (e.g. vertical versus horizontal integration etc) rather than agreeing on what outcomes and results are desired by patients locally and fully utilising existing systems and flexibilities to achieve those as a first step. 

It is clear from the NHS Calls to Action during 2013 and 2014 that in order for the NHS to reform, to cope with the requirements of an ageing population and new technologies in a time of financial constraint, a reinvigoration and reinvestment in primary care is needed and this is more than just GPs or even GPs and pharmacists in combination.  As we have said in our evidence to the Health Committee’s current inquiry into primary care:

What is needed is a [primary care] system that supports the population - and older people in particular – in a more holistic way.  The crucial elements of this - sight, hearing, balance, teeth, medicines management, flu vaccination, weight, continence and mobility – can all be delivered effectively  in primary care. 

This needs leadership from the professions to work in a more joined-up way around individuals and their support systems (including social care, carers and the voluntary sector) at local level.  

Key requirements are:

-          cross-referral  between primary care professions for first-line care.

-          simple but secure IT connectivity between primary care professionals (eg GPs, optometrists, community hearing, dentistry, pharmacy) and between those professions and secondary care  to facilitate shared care, joined-up working and rapid intervention and support by professionals when and wherever needed.

-          better use of the flexibilities in the new primary care contracts agreed over the past 10 years to achieve these aims.

-          cost-effective investment in services within the community that can reduce the pressures on hospitals  and general practice, support prevention and safe, accessible patient care.

-          an England wide framework for service delivery, providing for consistent quality of care and ensuring further devolution does not lead to fragmentation or piecemeal approaches.

We stand by this view and, in this response to the CLG Committee, have focussed our comments  on the following central question:

“The devolution of health spending to Greater Manchester and how it will affect delivery of health services locally—and the merits of extending this model to other cities and counties.”

The devolution of health spending to Greater Manchester presents an ideal opportunity to reconsider the way health care is delivered to Greater Manchester’s population and as a potential forerunner for other areas.

Reinvigorating and expanding primary care and provision in the community is vital and, as above, goes far more widely than general medical practice (GPs). GPs (even working in federations and with the target of 5,000 more doctors working in general practice across the country) cannot achieve the scale of transformation required alone in isolation from the rest of primary and community care. Optical practices, pharmacies, dental practices and community hearing practices are all integral to this effort and, in the case of eye health, community optical practices should be clearly identified as the first point of contact for patients in Greater Manchester – and elsewhere – with eye health problems.

Optometrists and opticians are eye experts in the community and, by using them as such, can take much pressure off GPs and hospitals.  

NHS Sight Testing Service

12.8 million NHS sight tests per year, commissioned by NHS England under the General Ophthalmic Services (GOS) contract, are carried out in total of which the large majority take place in 6,000 community optical practices in England, while over 400,000 NHS sight tests are delivered in a domiciliary setting.[1] In addition 5-6 million private sight tests are also carried out.  GOS plays an important public health role in providing vision correction for the majority of the population who need it and case detection for those who need further investigation or treatment (about 5% of patients). Early detection of sight threatening conditions is essential to reduce avoidable sight loss.

At a total UK annual cost of £0.25 billion this is the most cost-effective public health service in the NHS.   It is important that Greater Manchester’s population continues to benefit from this demand-led service, and the national cost-effective arrangements but with commissioners and providers working more closely together as partners, and through the Greater Manchester Local Eye Health Network (LEHN), to improve access and outreach for hard-to-reach groups and in areas where high deprivation impacts on people looking after their eyes. Existing contract flexibilities explicitly provide for this.

Eye Health beyond the Sight Test 

But there is so much more eye care that can now be safely delivered outside hospital and close to home. Community optical practices have readily available trained professionals, premises and high tech equipment in accessible locations to meet most of the population’s eye health needs. Given the burdens on GP surgeries and the rising demand for hospital eye services, it is important that areas such as Greater Manchester ensure optical practices and their human and physical resources are fully utilised.

Demand for hospital eye services has increased by 8% in the two years to 2013-14.[2] In 2013-14 there were a total of 6,807,664 ophthalmology outpatient appointments in England. This represents the second highest number by speciality across all hospital departments.[3]  

In many ways Greater Manchester has led the way on eye health in recent years building on successful models from Wales and elsewhere and it is vital that these NHS and health successes are maintained and fully integrated into Great Manchester’s health spending devolution programme. Of particular importance is the ‘minor eye conditions service’ that has been commissioned by Stockport, Bury and Heywood, Middleton and Rochdale CCGs. This service allows community optical practices to accept referrals from GPs and pharmacists for patients with eye problems that are outside the scope of the NHS sight test, who would otherwise have gone to hospital or A&E, in the community. In the year to 31st July 2015, the Stockport service saw 4,018 patients attend local optical practices with eye health concerns such as red eye or dry eye. [4]  GPs can refer patients into the scheme and patients can self refer. 78% of patients referred to these services can be managed out of hospital.[5]

Other community eye health services in Greater Manchester include pre cataract operation consultations in Stockport and Wigan CCGs’ areas, a post cataract service in Stockport CCG and glaucoma repeat readings services in Heywood, Middleton and Rochdale and Stockport CCGs.

Community eye services that should be standard across Greater Manchester, and indeed the rest of England, and for which tried and tested pathways already exist, are:

-          urgent eye care – (MECS)

-          cataract pre and post operation

-          glaucoma management

-          dry AMD management

-          eye care for people with learning disabilities

-          eye care for homeless people

-          low vision

-          children’s vision

The devolution to Greater Manchester provides the opportunity to expand these services to the whole of Greater Manchester: delivering transformation at scale in the terms of the Five Year Forward View.

In this way significant savings could be achieved across the Greater Manchester system through agreed pathways with common standards, outcomes and experience measures ideally at one fixed fee to save commissioning costs.

The same applies to England and, ideally, Greater Manchester and other areas will provide a cost-effective outcomes-focussed model which the rest of the NHS in England can follow.

In Greater Manchester, LOCs, with support from the Local Optical Committee Support Unit (LOCSU), have been working with CCGs and the LEHN to deliver both better health outcomes and better use of NHS resources. We consider it vital that these strong relationships are fully drawn upon during the devolution process in Greater Manchester.

Rest of England 

With regard to eye health, parts of Greater Manchester have been leaders in commissioning in recent years.  We would expect that, if further health spending devolution takes place elsewhere, other areas will draw upon Greater Manchester’s successes. This would be supported by the development of national frameworks for service delivery in areas such as eye health to ensure that services can be commissioned effectively, quality maintained and post-code lotteries avoided.  

We believe the Cities and Local Government Devolution Bill presents an excellent opportunity to develop community services further and would like to offer our support.

September 2015