Ophthalmology summit: 14 October 2024

The Welsh Government commissioned an external review of eye care services in Wales that was undertaken by Andy Pyott, a consultant ophthalmologist from NHS Highlands in Scotland on behalf of the Royal College of Ophthalmologists during 2020 and into 2021. That report was published in late 2021 with a number of recommendations particularly centred around making the most effective use of the workforce that we have in Wales.

Following this external report, the first ministerial summit for ophthalmology took place in November 2022, where NHS Wales, the NHS Executive and clinicians were challenged to drive efficiencies within the current system to improve performance in the short term to formulate a strategy and turn the recommendations of the external report into practical solutions.

There has been progress since the last summit, including:

• the getting it right first time (GiRFT) team have worked with each health board and produced action plans for improvements in efficiency and productivity against cataract and glaucoma pathways
• optometry contract reform has introduced new clinical pathways to support hospital eye care services and enable the shift of lower risk cases to be managed in primary care optometry practices
• the ophthalmology clinical implementation network has been established, through which the ophthalmology clinical strategy has been developed

However, performance against the R1 targets, those patients at greatest risk of permanent irreversible sight loss, has been static for over a year with over 50% of patients waiting longer than their clinically agreed review date and waits for cataracts and other conditions also growing.

The ministerial ophthalmology summit held in October 2024 brought together executive officers, operational managers, clinical leads, senior clinicians and the third sector from across Wales to discuss and agree actions to improve outcomes and performance.

The focus of the summit was glaucoma, medical retina, and cataracts with a view to agreeing actions, sharing best practice, and addressing any barriers to improvement.

The NHS Wales Executive’s national director for planned care gave a presentation on the current position of ophthalmology services across Wales, highlighting the variation between health boards. The key points included:

• due to an aging population, projections for 2033 indicate an increase of 31.3% in demand for eye care services for patients aged 80 years and older
• over the next 9 years the number of cataracts incidence is set to increase by 11%, which translates to a minimum required capacity for cataract surgery above 25,000 cases per year
• glaucoma prevalence is expected to increase by 13% from 88,700 to 100,130 over the next 9 years
• the major retinal diseases, age related macular degeneration and diabetic retinopathy are expected to increase by 13%
• secondary care demand (referrals) is above pre-Covid rates and continue to increase, and even though outpatient activity is close to historic levels, overall waiting list volumes are increasing at a significant rate
• the most at-risk patient group (R1) is increasing, with the volume in excess of 100% past their target date more than double that in 2019 and 2020
• treatment activity remains below pre-Covid levels, resulting in increasing volumes of patients waiting for treatment
• additional pressures from the pending arrival of treatments for previously untreatable conditions, such as geographic atrophy, could add approximately 30,000 additional appointments for injections per year
• the integration of primary care into eye care services has made positive improvements to service activity levels and there is further potential to manage patients outside of secondary care
• primary care activity has markedly increased in the first 6 months of 2024 and 2025
• there are opportunities to improve demand management through optometry pathways in primary care, fully implementing WGOS 4 patient filtering for glaucoma and medical retina and fully implementing WGOS 5 independent prescribing optometrists
• further use of the primary care services can reduce the secondary care demand, as well as improved usage of PIFU/SOS and HVLC treatment opportunities
• there is currently no national perspective on the overall harm being experienced in Wales or how that harm is being mitigated - the numbers reported as patient safety incidents nationally are small and may not be reflective of the total harm given the high volume of patients that remain on waiting lists

The Cabinet Secretary for Health and Social Care acknowledged the challenges facing eye care services and the impact of sight loss on individuals, emphasising the need for improved access to care and highlighting the new clinical ophthalmology strategy.

The following expectations of health boards were set out:

• the need for a strategic approach to manage increasing demand for eye care services, including further integration and utilisation of primary and community care optometrists
• the need for consistency and efficiency across health board performance to ensure equal levels of care for patients across Wales
• address inefficiencies within the system and implement actions and recommendations set out by WGOS and GiRFT
• encouraged health boards to work collaboratively and regionally across high volume areas of the service

Current waiting times and variations in performance were highlighted. Addressing this is a key priority for government. To do this, health boards will need to:

• implement the national optimised pathways
• ensure capacity is used appropriately and the most appropriate patients are referred to secondary care
• invest in workforce capacity and reconfigure fragile services
• take advantage of any technological and digital innovations to help improve efficiency

The national clinical lead for ophthalmology presented the national clinical strategy for ophthalmology (NCSOphth).

Welsh Government commissioned the NHS Executive to develop a clinically led blueprint for the delivery of ophthalmology services across Wales. In developing this strategy, the clinical implementation network has engaged with ophthalmology consultants in a series of workshops, as well as:

• patient facing non-medical clinicians
• administrative support staff
• health board operation leads
• primary care teams
• Health Education and Improvement Wales (HEIW)
• third sector partners

Wales currently has one of the lowest consultant ratios per head capita across the 4 nations and the workforce faces challenges with recruitment and retention in all ophthalmology medical grades.

Ophthalmology estates in Wales are in poor repair and lack the physical capacity to adequately meet the demand of the service.

No ophthalmology unit in Wales has implemented a fully functional electronic patient record (EPR) system despite significant investment since 2019. Primary care optometry also has no access to secondary care records limiting the implementation of WGOS pathways and solutions.

The strategy proposes a number of solutions to address these themes. Health boards and stakeholders were asked to commit to the implementation of this strategy. The 4 strategic elements of the document are:

• organisational reform: maximise the workforce to best treat patients
• clinical networks: to provide equality of care
• pathway transformation: improve end-to-end pathways and patient experience
• sustainable delivery model: work across health board boundaries both organisationally and physically

The national clinical strategy for ophthalmology underpins the work of the ophthalmology clinical implementation network (CIN). It is the framework for a series of reports that will be published in the coming months including:

• sub-speciality reports
• workforce training and research
• digital
• patient centred care

The summit then focused on the serious risks within the system supported by presentations from the president of the Royal College of Ophthalmologists and the Wales Vision Forum.

Risks within ophthalmology services

The presentation from the president of the Royal College of Ophthalmologists (RCOphth) on the risks within ophthalmology services highlighted:

• Importance of sufficient consultant workforce and investment into ophthalmology units to meet service demand. Workforce shortages are a key reason why capacity is lacking. To address workforce shortages and improve delivery of eye care, RCOphth is calling for a phased increase of 36 ophthalmology training places in Wales by 2031. In 2023 there were 62 FTE consultants in Wales, equating to 1.97 FTE consultants per 100,000 population. This is significantly lower than England and Scotland. The minimum recommended consultant to population ratio for hospital eye services is 3 to 100,000.
• The UK-wide 2024 survey of ophthalmology clinical leads found that sufficient clinic space was the joint most important factor for improving services, cited by 71%. 
• There has been a big increase in the number of highest risk patients waiting for care, with the number treated remaining relatively static.
• Important that serious incidents are captured and RCOphth guidelines on harm are followed. Conditions that can lead to irreversible sight loss must be prioritised, and health boards agree a regional strategy for addressing the risks.
• Concerns that the rollout of EPR for ophthalmology (OpenEyes) has stalled. Universal adoption interoperable EPRs and shared imaging standards are needed to facilitate communication between health boards and primary and secondary care.
• The need to prioritise patients with conditions leading to preventable, irreversible sight loss by adopting high volume activity and performing bilateral sequential cataract surgeries where appropriate.
• Refining job planning, job descriptions and training opportunities to create greater workforce appetite towards ophthalmology recruitment and to help retain staff.

Concerns from a patient perspective

The presentation on behalf of the Wales Vision Forum shared a number of case studies and highlighted issues from a patient experience perspective, including:

• Many patients are experiencing frustration and desperation with the service due the fear of permanent sight loss caused by long waiting times and poor communication from health boards. 
• Barriers to care include:
  • issues with non-emergency patient transport as these do not always accommodate patients with sight loss
  • eye care clinics can be inaccessible to patients with poor sight or sight loss
  • pressure on workforce can sometimes lead to unhelpful interactions
  • inaccessible communication and information has resulted in 1 in 3 blind and partially sighted patients missing appointments
• Importance of the eye care support pathway, which outlines support needed at each step of the pathway for a patient’s care. 
• Consistency of the role of the eye care liaison officers, and funding for them to be allocated as part of core ophthalmology staffing budgets.
• Concern about the low level of serious incident reporting and the lack of strategic oversight and scrutiny is masking the extent of irreversible sight loss being caused to patients from treatment delays.
• Need for better integration between health boards and third sector organisations to provide ongoing support for patients and ensure they are not left without help after their clinical appointments.

This part of the summit focused on the good work that is underway to transform services and how these can be shared across health boards. A number of presentations were given from the NHS Executive and 3 health boards as follows.

National pathways and approach

The presentation from the national planned care programme within the NHS Executive focused on the clinical agreed pathways. The presentation:

• explained the role of the ophthalmology clinical implementation network (CIN) in driving improvements in ophthalmology services across Wales by setting standards and developing service pathways
• encouraged collaboration between health boards and the CIN for patient access equity, partnerships with primary care and the third sector, site improvements, and subspecialty focuses
• highlighted how they would support the implementation of the ophthalmology strategy by addressing:
  • workforce challenges
  • estate improvements
  • improved IT infrastructure

Glaucoma pathway development

The presentation from Cardiff University focused on the improvements that have been made on glaucoma pathway, including:

• benefits of utilising "teach and treat" clinics to provide clinical placements for optometrists to gain higher qualifications and support waiting list reduction
• success in reducing referrals by discharging patients to and managing cases within primary care and community care clinics
• clear hierarchy of glaucoma professional qualifications for optometrists and clear guidance of which patient’s optometrists can manage safely in primary care
• long term benefit to train more optometrists to manage glaucoma in the community
• evidence there is potential for primary care optometrists manging glaucoma patients supported by WGOS contracts to:
  • reduce waiting times
  • maintain patient experience
  • release hospital capacity

The presentation made reference to a recent paper evaluating the role of primary care optometric services managing glaucoma and age-related macular degeneration outside of hospitals.

Refocusing our medical retina services

The presentation from Swansea Bay University Health Board explained how the health board has transformed its medical retina services. Key to this transformation was:

• implementation of consistency in the pathway through the use of simple algorithms
• optometry changes:
  • established the community AMD and diabetic retinopathy referral refinement pathways
  • increased use of independent prescribing optometrists and an established pathway
  • transitioning these pathways and embedding into the WGOS 4 and 5 pathways within the health board
  • result of changes for diabetic retinopathy is a total waiting list of 2111 patients with 96% seen at target or within 25% of target date
• hospital changes:
  • the development and use of non-medical practitioners for injection, review, laser, consent, and uveitis
  • implementation of treat and extend and prudent drug choices
  • growth of virtual clinics
  • setting up of 2 clean rooms

Cataract pathway developments

Hywel Dda University Health Board highlighted the work being undertaken to implement the one stop cataract clinic to reduce patient attendances and improve patient experience by at least 25% before surgery by September 2025.

The expected benefits of the programme include:

• increased service productivity
• better patient experience
• greater workforce development
• improved service processes
• a reduced health board carbon footprint

The health board are part way through the implementation of this pathway and the next steps include:

• roll out full timetable of one stop cataract clinics in Glangwili Hospital from November 2024
• work through rolling out one stop cataract clinic in North Road eye clinic in Aberystwyth in November 2024
• standardised process for cataract prioritisation to assist with streamlining urgent and routine cases
• finalise standard operating procedure for management of patients moving from stage 1 to stage 4
• to review theatre delivery with a view to increase delivery in line with time saved pre-operatively

Key points from the group discussion included:

• Better communication between health boards and patients is needed to manage patient expectations of pathway changes to reduce confusion, delays in treatment and the re-referral of patients. It was noted that the CIN communication and accessibility subgroup is working towards a standardised letter for Wales available for health boards to utilise.
• Health boards should implement the national clinical strategy for ophthalmology to standardise the quality of care across Wales.
• The patient voice must form part of the development and implementation of all aspects of the national clinical strategy for ophthalmology.
• Need to invest in ophthalmology workforce and estates to improve service delivery.
• Importance of digital transformation to drive sustainable improvements within ophthalmology services.
• Action is needed to address those glaucoma patients who may not be given guidance on the use of their prescribed eye drops.
• The need for comprehensive planning for all aspects of ophthalmology.
• Highlighted the under-utilisation of Powys Teaching Health Board eye care theatres and the opportunity to consider opportunities for mutual aid and collaboration with other health boards.
• Health boards should ensure that clinical teams understand how to report and capture patient harm. The Cwm Taf Morgannwg University Health Board’s ophthalmology harm review panel was used as an example as to how this could be done.
• The role of eye care liaison officers as a support for patients during their sight loss diagnosis by also providing guidance to patient’s post-diagnosis and post-discharge.
• Health boards need to actively pursue better integration and co-ordination with non-clinical services, such as adult social care vision rehabilitation services and third sector emotional and practical support, to maximise opportunities for patients to live independently at home.

The following commitments and actions were agreed and progress against these will be monitored:

• Health boards to implement and monitor the impact of the use of optometry WGOS pathways to reduce secondary care demand and increase capacity.
• Health boards, with the support of the CIN, to adopt integrated pathway models for glaucoma, medical retina optometry/ophthalmology pathway and one stop cataract pathway.
• Health boards in their IMTPS to increase cataract capacity in line with their demand and capacity analysis and plan how bilateral surgery can be implemented.
• Health boards to respond to recommendations in the national and local GiRFT reports.
• Health boards to move towards the implementation of high volume mixed complexity lists.
• The CIN to develop and implement a standardised harm reporting protocol based on the Royal College of Ophthalmologists’ guidelines across all health boards.
• Welsh Government to expedite the implementation of the electronic patient record (EPR) system to improve communication and efficiency between primary and secondary care and improve patient safety.
• HEIW to conduct a workforce review to identify gaps and needs across all levels of ophthalmology staff, including non-clinical roles.
• Health boards to ensure that patient communications are accessible and that appointment letters are sent in formats that patients can read independently.
• Health boards to develop business cases outlining the investment needed to achieve sustainable ophthalmology services, including workforce and estates improvements.