“The relationship with optometry, for us in secondary care, is really important”

The Eyes Have It is a partnership of Macular Society, Fight for Sight/Vision Foundation, RNIB, Association of Optometrists, The Royal College of Ophthalmologists, and Roche. Roche has funded the activities of the partnership.

Christiana Dinah, consultant ophthalmologist in Brent in north west London, joined The Eyes Have It’s panel at 100% Optical to discuss how optometry can be utilised to prevent avoidable sight loss in the UK population.

Ahead of the panel, OT caught up with Dinah to discuss how the relationship between optometrists and ophthalmologists can be built upon, the importance of digital connectivity, and the opportunities and challenges of outsourcing NHS care to independent sector providers (ISPs).

As part of the secondary care workforce, how do you build relationships with optometrists in the community?

The relationship with optometry, for us in secondary care, is really important. Essentially, they are our clients. They are the ones who refer patients to us. It’s super important that they are kept in the loop in terms of the care we provide for their patients.

As a department, we host pre-registration placements, and also teaching events with the Local Optical Committee (LOC). Those, I have found really useful. We can tailor our topics to what optometrists’ knowledge needs are. I’m a retina specialist, so I tend to focus on content around that. But my department has ophthalmologists who specialise in other areas, who I can liaise with and say, ‘optometrists need this topic.’

We also invite optometrists into our department for relationship building, usually framed around explaining or sharing the services we provide, or [to share] any innovations we’ve made or any changes to the patient pathway, so they’re aware. We’ve done that for cataracts and for a lot of our retina pathways, as we increase the treatments that we have available.

Because we’re a very research-active unit, and we have a lot of trials going on, and we recognise the importance of access to those cutting-edge treatments, we see the need liaise constantly with each optometrist so they’re aware and they can prepare their patients for those trials.

One of the things we’ve done, which is now being adopted across the country, is to create a community research champion. That role has worked so well that it is now being adopted in different regions.

In building those relationships, and in inviting community optometrists in, we get to learn what their frustrations are. One of the things they say all the time is, ‘we refer patients in, and we don’t hear back.’ Their GP gets copied in, but their optometrist doesn’t. Optometrists don’t know if their hunch was right or not.

I find that that’s really the chasm that remains between primary and secondary care. We have all these things in place to try to build our relationship with optometry, but more needs to be done, because without that continuity, the relationship suffers.

In building those relationships, and in inviting community optometrists in, we get to learn what their frustrations are

What are your thoughts on ophthalmology services being more integrated into the community, and into primary care?

I think that it is important, but that it needs to be done in a very supported way. Across the country, there are pockets of excellence – CUES, the Minor Eye Conditions Service (MECS), and so on. But it’s not systematically available everywhere. Where I work, I believe these enhanced services exist, so we don’t have minor procedures done in the hospital anymore. But there is a bit of a postcode lottery.

Recently, I had a patient who was under hospital care. Something happened to her vision, and she went to see an optometrist. They said, ‘You have another appointment in the hospital in two months. We could do a couple of scans, but you have to pay for them.’ She didn’t want to, so she didn’t do it. Sadly, they would have made a difference.

From my understanding in other regions, there are systems in place where patients would not have to pay for scans. So again, a postcode lottery, which means that there is an inequality in the system. It really doesn’t conform to the NHS value of being free at the point of care for everybody. An overarching vision, and systematic planning for integration, would work.

There is huge pressure on NHS waiting lists, specifically for ophthalmology. What benefits can having those services in the community offer to patients?

A lot of our patients are elderly. Also, with the cost-of-living crisis, and getting to hospital versus being closer to your own home, there is an expense, which I think is often relevant.

Clearly, there is benefit there. But those services need to be integrated properly. We have diagnostic hubs; we have MECS. But we also know that these systems are in some areas and not in others. Who is making those decisions? How are we designing it so it’s an efficient use of our resources? That’s why it’s about having a plan, as opposed to a few brilliant ideas popping up across the country.

Private providers are, in some cases, taking on work to help ease the NHS waiting list. One criticism of them is the notion that they are taking on simple work and leaving more complex cases to the NHS. What are your thoughts on this?

It’s very interesting. The Health Foundation, an independent think tank, published its assessment in 2023 of the impact of private sector providers. Actually, the waiting times were not lower in the private sector, because the volume that they now do, compared to what they were doing before, has significantly increased. 

The Health Foundation has shown that, even though we know that the volume of work in the independent sector is much higher, it is still 60% cataracts and it is not equally distributed. In affluent areas, you have more independent sector providers than you have in deprived areas. Deprived areas have longer waiting lists already. So, this is actually making it worse. The waiting times and access to fast turnaround is, again, worse in the deprived areas than the affluent areas.

Traditionally, when performing cataract surgery, you have a case list. You might have six cases, let’s say, in a theatre list, and maybe three are complex. But they are interspersed with easy ones. You start, and it’s easy, then it’s hard, and then it’s easy.

Now, imagine six complex cases, from beginning to end. At the end of the year, you’re burnt out. There’s no respite – it's all complicated. That’s not good for the NHS workforce. So, when people say, ‘well, some of the NHS workforce might go to the independent sector.’ Well, yes – wouldn't you?

I think we have to be realistic. There are a lot of things that cause job satisfaction. Finance is one of them, but depending on who you are, it might be a small part. In general, it’s the case mix, work life balance, and work balance. There are a whole lot of things in there.

I personally feel like ISPs are very valuable. They do have excess capacity that we can utilise within the NHS, but it needs to not be ad-hoc. If it’s about addressing the waiting lists, let’s place ISPs in places where there are waiting lists – not in places where we have zero waiting lists, because they are nicer areas. It can’t be, ‘I feel like opening my little ISP in Chelsea or Mayfair, so I’ll do that.’ Identify where the problem is, and where we don’t have capacity, and solve that issue. I think ISPs are useful and they are needed, but within a framework, as opposed to a free for all, which is what I think we’re seeing now.

There are nearly one million people on the eye care waiting list. Can we address that? Probably, but only with a national strategy and a national overview

Do you have any other thoughts on the subject of the NHS workforce being driven into private practice?

The national contract for consultants allows private work. We can work in the NHS and we can work privately. I have no issues with people working either fully privately, or privately for an ISP. But this is beyond that. This isn’t a few people, part-time. This is a whole scale depleting of both work and clinicians to ISPs, leaving behind just some people.

As a consultant, my labour is wanted. I can go to the independent sector; I can go to Australia or America. There are a lot of patients who don’t have that recourse. They can’t just go anywhere. This is where they live; this is where their treatment has to be. So, we need to be thinking about that. And not just ISPs, that includes the NHS. We don’t seem to have a concerted or a national overview of the waiting lists.

I can give you an example of a time in my unit when we had no waiting lists. We had space, so we said, 'please send them to us.' But that needs to be done in a more concerted fashion. It’s got to be done across the NHS.  We need to look at capacity as a whole, across the system: private, public, based on where capacity is. There are nearly one million people on the eye care waiting list. Can we address that? Probably, but only with a national strategy and a national overview.