“GOS in England is very underfunded” – Association of Optometrists

OT  asked three optometrists: if you had the ear of the new Health Secretary, what would you say?
Lucy Miller
03 November 2022
I would give optometrists in the community more ability to provide primary eye care for patients, by making it easier for all optometrists to become IPs.

I would walk the new Health Secretary through the journeys that my patients have had in accessing basic primary eye care. I would walk him through my corneal ulcer patient, and how it took her four days to see the consultant because of letters ping ponging back and forth, and arriving at the hospital to find that the consultant wasn’t there, for something I should have been able to treat her for on the day. I’d walk him through the journey of a retinal detachment patient, where it took three days to find a consultant who could operate on her. I would walk him through the simple case of an allergic conjunctivitis patient who has a chronic condition, who could have been treated by me in the chair months before they finally got to see the consultant. I’d walk him through a patient with a visual field defect, who I referred in March, who was just in this week, for a sudden loss of vision.

I would walk him through those journeys, and say, “it seems like you’re playing with fire here.” It seems that primary eye care is being thrown on consultants at the hospital. Consultants need to focus on surgical procedures; they don’t have time to be seeing all these primary eye care conditions.

I’ve come from a country where you would never go to a hospital for a corneal ulcer – you would see your local optometrist

Valarie Jerome

I come with a different perspective, because I’ve come from a country where you would never go to a hospital for a corneal ulcer – you would see your local optometrist. It frustrates me, having practiced as a therapeutic optometrist for over 10 years in the United States, to come here and be unable to qualify because it’s too difficult to be taken on for the hospital placement days. To see these patients and know I could treat them in the chair, and to know that they might fall through the cracks and not get the treatment that I refer them for, is extremely frustrating. My focus, if I had his ear, would be: “let’s work on getting primary eye care into our communities and out of the hospital, because the hospitals can’t see everyone.”

I’ve lived in this country and practised here as an optometrist for 13 years now, and for 13 years I’ve been very frustrated, especially when I’m purely doing refractions and referring patients. Would I like to be able to use the knowledge in my head to sign a prescription and do that part of my job? Yes. But the bigger thing is, I’d like to see my patients get the care that they need much more quickly, to preserve their vision and maintain a good quality of life.
I’ve come from a country where you would never go to a hospital for a corneal ulcer – you would see your local optometrist
I think there are two issues. One is the utilisation of optometrists for more advanced practice. So, using optometry practices in the community, particularly IPs to treat patients who would otherwise be referred to hospital.

There are a lot of schemes around the country, but it’s very disjointed. Lincoln has got quite a good scheme. We see pretty much all suspected glaucoma rather than it being referred to the hospital, and we only refer on people who need hospital treatment.
I feel there is an underutilisation of optometry skills. I think that optometry should be structured for the future, so that all optometrists should be IPs on qualification. It would be a sea change for the profession, for those skills not to be confined to six or seven people in the county.

All optometrists should be IPs on qualification. It would be a sea change for the profession

Martin Smith

The other major issue is the underfunding of primary care optometry for routine care, and the knock-on consequences that has. If primary care was funded properly, you’d get fewer referrals into secondary care and into the schemes and it would save money in the long run – but they don’t look at it that way. So, proper funding, if you want optometrists to do something other than a refraction, checking if there’s something wrong, and referring it on.

Ophthalmology has the biggest referral rate of any speciality, because they don’t pay optometrists to do anything other than refer people on. I don’t do GOS: I practise privately, and I manage huge amounts during those appointments. People don’t need to go to secondary care the vast majority of the time, and they wouldn’t have to if the system was sorted out.

I think the utilisation of IP optometrists in the community to manage those referrals is already happening, and it could happen to a greater extent if we have more optometrists with more qualifications. Everything is going that way. Some harmonisation of these schemes, and funding for them, would be nice.

There is also the issue of segmentation. I’m in Lincolnshire, but I live in Nottinghamshire, so we’re not far away. If someone has a GP in Nottinghamshire, I don’t know what I’m referring them into. I can’t refer them and know that they’re going to see an optometrist, and they can’t come back and see me because their GP is five miles in the wrong direction. That just seems nuts, to me.

The new contract in Wales looks promising. These schemes obviously work. The number of IP optometrists in Scotland far outstrips the proportion in England, and it’s because there’s an incentive to do it. These schemes will, maybe, result in a change in the attitude in the government.
All optometrists should be IPs on qualification. It would be a sea change for the profession
One of the things we see in day-to-day practice is that patients are having to wait. The waiting times for cancelled appointments have gone up, because there isn’t the capacity in secondary care. It would be nice to see action to try to bring down those waiting times and make the best use of primary care optometry, to try and reduce the burden on the hospital eye clinics.

One of the things that’s needed for that is a wider commissioning of services. Services in primary care at the moment are not equitable. There isn’t uniform access to urgent eye care within community optometry. Enhanced services need to be commissioned throughout the country to allow people to access eye care, rather than patients having to be referred to hospital eye clinics for assessments.

Enhanced services need to be commissioned throughout the country to allow people to access eye care, rather than patients having to be referred to hospital eye clinics for assessments

Tushar Majithia

[I would ask the Health Secretary] to utilise the skills and resources within primary care. What needs to happen is to engage with primary care optometry and look at allowing the commissioning of services throughout the country, with a more uniform approach to eye care pathways. At the moment this type of service is very scattered around the country, so there isn’t equity to access it.

It needs to be more equitable throughout the country. For example, in our area, there’s no access to urgent eye care in primary care, so patients who need urgent eye care have to go to accident and emergency or pay privately to have an assessment within an optical practice, which isn’t ideal for patients who need to be seen quickly for urgent eye care problems.

We do have an advanced service in the county, but that doesn’t include urgent eye care, so it excludes services such as assessment of flashes and floaters or red eyes, painful eyes – certain eye conditions that ideally need seeing straight away. Patients are having to pay privately to have those assessments, because those are the kinds of things that are not covered by GOS.

Having a review of GOS like they have done in Wales and Scotland to improve and modernise it would be a good start, so patients can get a better service. GOS in England is very underfunded. So, a better funding of the GOS scheme and an overhaul so that we can make use of the technology that we have in practice, as well as being better funded for the services that we can offer.

There’s an emphasis in the new Welsh contract on prevention and self-care, which is interesting, and that’s something that needs to be looked at in England. Many optometrists have tried to offer it within their practices, but it’s not something that’s funded.

Other aspects are things like the Low Vision Service, for which they have a really good service in Wales. Once again, in England there isn’t an integrated Low Vision Service that has a multidisciplinary approach to provide that service. Some areas provide a Low Vision Service, but it doesn’t allow for a partnership working with different areas of care: social care and hospital eye departments, working together with practices to provide the optimum service for patients.

The other thing is the integration of IT with primary care optometrists. We don’t have access to hospital records or patients’ NHS records, so when patients do come and see us for an eye problem, there’s no way of knowing their previous history. Our records are not linked to theirs. Quite often that can lead to referrals for issues that patients have already been seen for by the hospital eye departments. It can lead to inappropriate referrals if we don’t have access to the records. It would be a be nice to have a more integrated IT system where we can have access to patient records.

OT  asks…

Which of the following do you think should be the NHS’s top priority when it comes to eye care?

  • More accessible training for IP optometrists

    8 10%

  • Increase in the GOS fee

    54 70%

  • Wider commissioning of enhanced services

    9 11%

  • Addressing issues of segmentation across different regions

    3 3%

  • Improved IT connectivity

    3 3%

  • Something else

    0 0%

Enhanced services need to be commissioned throughout the country to allow people to access eye care, rather than patients having to be referred to hospital eye clinics for assessments
More accessible training for IP optometrists
Increase in the GOS fee
Wider commissioning of enhanced services
Addressing issues of segmentation across different regions
Improved IT connectivity
Something else
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Until optometrists are properly remunerated for their professional care and time
rather than the derisory and insulting fees that are paid currently- the pie in the sky aspirations of the three aforementioned practitioners will never be realised
The majority of the public will not pay the costs of the supplementary tests that we have to do during the consultation-HM government considers the GOS NHS fee scheme is considered adequate remuneration for Optometrists time and until this changes-no progress will be made

Report 8
Oops, wrote that message whilst doing visual fields. Can someone delete it & I’ll tidy it up & repost!
… and yes my favourite word is ‘useful’.
Report 29
This is an interesting commentary.
I think the way that the poll is set up is not particularly useful. Is it useful to have more IPs qualifying when there is nothing useful for them to do within the NHS?
This is the problem we have in Scotland [hopefully soon to be addressed]; there there are 100s of IPs who are not able to increase their competence & scope of practice, post-qualification, as there is no mechanism for the ‘juicy stuff’ to be directed their way. Hence, we most of them are mostly only prescribing lubricants.
You can’t pull the cart without any horses!
Report 25
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