The role of optometry in revolutionising glaucoma care
Why we believe utilising the optometric workforce can improve the way in which glaucoma care is delivered to patients in England, and could save the NHS £90 million per year in glaucoma care in 2030
Executive summary
The NHS is struggling to cope with the demands of an ageing population, and the increase in patients with chronic health conditions. Glaucoma is costing the NHS over £520m a year to manage. A collaborative approach to glaucoma care, which utilises the existing, extensive, highly skilled optometry workforce alongside secondary care, could immediately reduce the cost burden by £70m. A national approach is needed to the commissioning of glaucoma care in optometry, eliminating the postcode lottery of patient care, and ensuring maximum efficiency and value for money.
What’s happening?
Glaucoma is the term for a group of largely chronic conditions that damage the optic nerve, leading initially to a loss of peripheral vision that may ultimately cause blindness.
There are an estimated 1.39 million people in the UK living with ocular hypertension (OHT) and a further 708,000 living with glaucoma.1
Glaucoma accounts for around 20% of outpatient appointments.1
The number of people living with glaucoma is predicted to increase by 18% in the next 10 years. Follow up appointments for glaucoma are predicted to increase by 20%.
Currently, most patients with glaucoma are seen and reviewed within hospital eye departments. This usually involves patients over the age of 70, who are unable to drive as their examination will often involve pupil dilating drops that blur their vision. These patients therefore are likely to be travelling by public transport, or collected by patient transport, or reliant on friends and family to take them to their hospital appointments.
These visits to the hospital may occur multiple times per year as patients are often scheduled on different days for differing tests. One visit may involve a review with an ophthalmologist, and another may involve being seen by a nurse or technician to have their visual field measured. These visits are expensive, time consuming and in many instances unnecessary for both the patient and the NHS.
Meanwhile hospital waiting lists have increased, and in ophthalmology stand at over 600,000.
Figure 1: Fu, Dun Jack, et al. "Burden of glaucoma in the United Kingdom: a multicenter analysis of United Kingdom glaucoma services." Ophthalmology Glaucoma 6.1 (2023): 106-115
In a 2023 paper by Fu et ali it is estimated that around 70% of patients seen in glaucoma clinics are at low risk of sight loss; this is supported by over 40% of patients having a diagnosis of OHT or being categorised as glaucoma suspects.
Figure 2: https://edgehealth.shinyapps.io/Ophthalmology_DF/ and Fu, Dun Jack, et al. "Burden of glaucoma in the United Kingdom: a multicenter analysis of United Kingdom glaucoma services." Ophthalmology Glaucoma 6.1 (2023): 106-115
The patients in these two categories lack the characteristic visual field loss that is typically necessary for a formal diagnosis of glaucoma, are lower risk and as such they are perfect candidates for optometric monitoring. Additionally, a significant proportion of primary open angle glaucoma patients could also be transferred to optometric care.
The mean number of yearly attendances to the glaucoma clinic for those patients with early visual field loss is 1.75 times per year with a standard deviation of 1.18; this rises to 2.60 visits per year for those with more advanced loss. Much of this is caused by hospital logistics, an inability to provide the visual field tests, imaging, and the clinician review in a single appointment. In contrast, optometry practices have a proven track record of delivering an efficient patient-focussed service, with capacity to incorporate multiple tests in one appointment, much of which could be translated into the delivery of glaucoma follow ups.
What’s the economic case?
The 2023 paper by Fu et alii looks at the true cost burden of delivering glaucoma care within secondary care in the UK. Crucially, the results show that the cost of caring for glaucoma patients is far more expensive than the current NHS tariff prices suggest, this includes the time of the consultant, support staff, diagnostic tests, medicines and procedures. The implication of this is that hospitals in the UK are being forced to redirect funds from other aspects of patient care to make up this shortfall; in turn, this means funding has to be diverted from other areas of care. Current NHS follow-up tariffs, those that are applicable to patients already under care, are paid at around £65-80. If two follow up appointments are paid, even for the lowest complexity patients, the NHS is cross-subsidising these patients by around £130.
The findings demonstrate that delivering glaucoma care at the current scale, via the current processes, creates an unsustainable cost pressure for secondary care in the UK. The work by Fu et al looks at the whole care pathway, including which secondary care staff are involved. Importantly, it shows that the cost of glaucoma care varies by disease variant. These costs can be categorised as follows.
| Patient category | Cost per patient per year | Total cost per year |
| Primary open angle glaucoma | £444 | £226,262,400.00 |
| Ocular hypertension | £320 | £97,664,000.00 |
| Glaucoma suspect | £289 | £76,874,000.00 |
| Other glaucoma diagnosis | £415 | £45,318,000.00 |
| Mixed glaucoma diagnosis | £342 | £74,648,000.00 |
To test how glaucoma care could be delivered in optometry practices, we have constructed an economic model.
This model looks at the potential cost saving, by delivering care in optometric practice via two parallel, but linked delivery mechanisms.
Depending upon the volume of care transferred to optometry, the model shows cost savings of between £37m and £76m per year that could be achieved, based upon 2020-21 patient volumes. Using NHS projections for patient volumes by 2030-31, before inflationary pressures are factored in, the model estimates it would be possible to save between £46m and £94m per year.
Figure 3: AOP modelling of potential glaucoma cost savings in the UK
Additional considerations have been addressed in the model: fixed costs; the need for consultant shared care in some instances; and the proportion of patients who will still be referred to the hospital. Even after allowing for these factors, the cost savings are significant.
For example, our economic model looks at the cost breakdown described by Fu et al and acknowledges that a proportion of the average cost of care, such as for medications and surgical glaucoma procedures, is unavoidable. Because of this, this cost is retained within the model.
The current care delivery model, which requires patients to attend the hospital multiple times for different procedures, is expensive and inefficient for those patients. As such, it is noted that our economic model does not factor in that financial impact on patient, including time away from work, lost productivity, travel and parking, either directly or indirectly for carers. Our view is that these additional costs are significant and meaningful, and contribute to the argument.
What needs to change
1. We think that glaucoma care should be delivered closer to where patients live, in locations which are easily accessible, by a well trained and well equipped workforce, with follow up appointments delivered within optometry practices
The details of how this will work takes two possible forms, articulated by the Royal College of Ophthalmologists in their ‘Glauc-Strat-Fast’2 document and supported by the College of Optometrists.
This document clearly sets out what additional training is required for optometrists to deliver care autonomously. We recognise that the challenge with autonomous management is that it is time consuming to achieve the highest qualifications, and the placements for training are difficult to obtain.
‘Glaucoma-Strat-Fast’ also sets out how care can be delivered collaboratively. It is this scenario which we think represents a unique opportunity for the NHS to utilise the optometric workforce and to revolutionise glaucoma care in the UK.
The current lack of a collaborative approach to care fails to utilise the highly skilled optometric workforce, which could ably supplement the insufficient number of ophthalmologists. In addition, the lack of universal commissioning leaves patients at the whim of local commissioning decisions, this embeds inequity between areas and demonstrates the postcode lottery of patient care.
2. Glaucoma follow up appointments are within the core skills of optometrists. We think the system needs to change to reflect that
Optic nerve head assessment, visual field assessment, intra-ocular pressure measurement and optical coherence tomography (OCT) assessment of the optic nerve are conducted daily by optometrists. They are well practised and experienced in their usage and adept at detecting and acting on deviation from previous values. The equipment required is commonly found in optometric practices throughout the UK.
Operating in conjunction with ophthalmologists to set parameters and management plans, optometrists can manage practically all glaucoma patients. The only thing prohibiting the near instant transformation of UK glaucoma care is the lack of a suitable mechanism for collaboration between optometrists and ophthalmologists. The system is hamstrung by a lack of connectivity, a failure to invest systematically and consistency in connecting the parts of the system that would allow collaboration.
If enabled, optometrists can monitor patients, with those patients that deviate from the predetermined management plan reviewed virtually by a consultant or an optometrist with higher qualifications in glaucoma, where possible refinements to the patient's medication will be made remotely with patients only returning to the consultant where it is essential for them to do so.
3. The lack of IT connectivity between optometry and ophthalmology inhibits patient care and needs to be improved
Improved IT connectivity needs to be a priority for the Government and NHS England to cut avoidable patient referrals between primary and secondary eye care. Read more in our policy position statement: Taking the right steps to drive IT connectivity for optometry.
4. Enabling significant volumes of optometrist-led glaucoma care to be delivered could save more than £90 million for the NHS by 2031 while increasing capacity within the service
We believe optometrist-led glaucoma care that takes a conservative, realistic approach can still be delivered at volume. To achieve this, we support a multimodal deliver mechanism. This means that, where available, patients who are transferred out of hospital will be managed by specialist optometrists with higher glaucoma qualifications.
We recognise that the number of specialist optometrists and their distribution is limited currently. Therefore, where there are not enough specialist optometrists, these patients will be managed in collaboration between optometrists and ophthalmologists, or optometrists and specialist optometrists. By utilising technology to review and provide oversight where necessary, patient travel and hospital visits can be reduced. This is consistent with the Royal College of Ophthalmologists’ Glauc-Strat-Fast model and as such should be uncontentious for all involved.
If the volume of patients seen at the hospital was reduced, it is possible that the more complex patients who still require hospital-based care could have all tests conducted on a single visit, which would further reduce costs and provide significant benefit to patients. In addition, valuable secondary care capacity could be created.
The Fu findings demonstrate that delivering glaucoma care at the current scale, via the current processes, creates an unsustainable cost pressure for secondary care in the UK. Using NHS projections for patient volumes by 2030-31, an optometrist-led glaucoma model has the potential to save between £46m and £94m per year.
Figure 4 Current patient journey
Figure 5 Transformed patient journey
What are we calling for?
In summary, a new approach focuses on three core areas:
- A collaborative approach to glaucoma care is needed, which utilises the extensive, highly skilled optometry workforce alongside secondary care
- Effective IT connectivity for optometry is required to facilitate and underpin this new mechanism of care. The current outdated, siloed approach undermines patient care
- Universal commissioning of glaucoma care for optometry to all patients is needed regardless of where they live, eliminating the postcode lottery of patient care.
References
- Fu, Dun Jack, et al. "Burden of glaucoma in the United Kingdom: a multicenter analysis of United Kingdom glaucoma services." Ophthalmology Glaucoma 6.1 (2023): 106-115.