Skip to main content

Introduction

The purpose of this paper is to provide a framework for the restoration of primary optometry services in Wales 2020-21. This is important to de-escalate the current RED status of the Covid-19 escalation plan, when it is safe to do so. Key considerations are to provide business continuity, due to the impact of restricted patient numbers whilst adhering to the social distancing measures to prevent disease transmission for the workforce and patients, which have impacted greatly on NHS Wales optometry service provision. This is also important due to the current and future financial uncertainties ahead. However, the ‘interruption to normal’ also presents an opportunity to use the de-escalation plan to deliver our aspirations outlined in ‘A Healthier Wales’ - prudent and value-based healthcare; forming a response that encourages access for all, evidence-based prevention and clinical care, based on need, delivered by the most appropriate member of the eye care workforce team.

This paper describes the response required to enable restoration of services in the immediate post lockdown phase. Further iterations, and development of the restoration phase, will be required to realise the opportunities that exist through the contract reform work that commenced prior to the Covid-19 pandemic. To achieve balanced, sustainable eye care services across the whole of the eye care pathway, it is recognised that service delivery in primary eye care has a vital role to play.

In Wales, our overarching strategic documents to steer optometry into the 21st Century are “A Healthier Wales” and “Prosperity for All”, underpinned by the key principles of prudent healthcare. The documents provide a clear policy direction for the provision of integrated, quality, sustainable and equitable eye care for citizens across Wales.

The 5 key aims of “A Healthier Wales” are:

  1. In each part of Wales the health and social care system will work together so that people using them won’t notice when they are provided by different organisations. New ways of joined-up working will start locally and scale up to the whole of Wales. We will make sure local services learn from each other and share what they do, because we want everyone in Wales to have access to the same high quality services. We also want services to use a single digital record to provide the most appropriate support and treatment based on a complete picture of a person’s needs.
  2. In each part of Wales we want to shift services out of hospital to communities. We want more services established to prevent and detect eye disease earlier and stop people becoming ill altogether. This will include helping people to manage their own health, and to manage long term illnesses. We also want to make it easier for people to remain active and independent in their homes and communities.
  3. In Wales, we will get better at measuring what really matters to people, and we can use that information to determine which services and treatments work well, and which treatments need to be improved. We will identify and support the best new models of health and social care so they scale up more quickly to the whole of Wales.
  4. We will make Wales a great place to work in health and social care, and we will do more to support carers and volunteers. We will invest in new technology which will make a real difference to keeping people well, and help our staff to work better. By making health and social care a good career choice, investing in training and skills, and supporting health and wellbeing at work, we will be able to get and keep the talented people we need to work in Wales. We will look to introduce digital advances that help staff work more effectively.
  5. To make our services work as a single system, we need everyone to work together and pull in the same direction. We think we can do this in a small country like Wales, especially if we as a government provide stronger national leadership, and make sure we keep talking – and listening – to the people who deliver and use our health and social care services.

Wales continues to lead the way in eye health care, across the UK and Europe; however, despite attempts to fully join up eye care services and pathways, the invisible boundaries remain. It is due to current secondary care service models as the emphasis has been on consultant led services, compounded by hesitancy to shift services into primary care due to a perceived loss of control. This is, also in part, due to current primary care business models as the emphasis has been on the sale of spectacles and contact lenses to sustain the optometry workforce and practice. The true benefits for health professionals and citizens across Wales will not been fully realised until the caution and boundaries are broken down.

Our vision for fully integrated, sustainable patient pathways must resolve these issues to ensure that, in line with prudent healthcare principles, the eye care professionals along each part of the pathway are doing only what they can do. The priority in primary care is the delivery of eye health care, and the priority in secondary care ophthalmology is treatment of blinding eye disease that only a consultant ophthalmologist can manage.

Our vision for eye health care in Wales is:

  • prevention of eye disease
  • early detection of eye disease
  • facilitation of self-care where appropriate
  • management of increased number of conditions in primary care
  • referral to a hospital only when absolutely necessary
  • when a patient needs hospital investigation and/or treatment, services are accessed in a timely manner
  • specialist secondary care ophthalmology services are supported and provided in hospital for patients that need them, adhering to prudent principles
  • primary care optometry services are developed to monitor patients locally in the community setting to increase the capacity for specialist secondary care ophthalmology departments to see appropriate patients in hospital
  • continued education and training for the whole workforce to support both primary and secondary care services

Optometry primary care contract reform has begun. To progress work at pace and facilitate the vision for eye care services nationally across Wales, an integrated workforce and pathways are paramount. The underlying principle is to ensure eye health is the focus of eye care and that optometry practices provide high quality support across the whole of the patient eye care pathway.

It is well documented across the UK and Europe that the demand for ophthalmology services is increasing with an elderly population living longer, increased detection and diagnosis of disease, and improved treatment options. It is equally well documented that the capacity, estates and equipment falls short of the increased demand and improved diagnosis and treatment.

To realise our vision for integrated, quality and sustainable services, the whole of Wales must ensure that we have the correct capacity to meet our demand, working together to deliver specialist services.

To achieve this we must:

  1. Reduce the demand on secondary care ophthalmology services by managing more patients in primary care optometry and reducing the number of referrals for specialist services.
  2. Ensure that only patients who need to be treated and monitored by a consultant ophthalmologist in a specialist eye unit are retained in the hospital eye service. This requires a shift of low and medium risk patients to be monitored in primary care with consultant ophthalmologist oversight.
  3. Procure technology solutions to support service change across the national integrated patient pathways, including electronic referrals, digital electronic patient record for shared care between health professionals and video consultation capability for health professionals and the patient.

The pause in provision of routine eye care services in both primary and secondary care during the COVID19 pandemic must be used to re-evaluate pathways and progress contract reform work. This will enable the change in service development required to meet the aims of A Healthier Wales and Prosperity for All.

Situation

On 17 March, the first eye health COVID-19 letter was issued from the Welsh Government Chief Optometric Advisor. The letter described how providing routine optometry services ‘as normal’ was no longer sustainable as people in vulnerable groups (older people and those with underlying health conditions) needed to reduce their inter person and close personal contact. In addition, optometry practices and services were experiencing growing numbers of Did Not Attends (DNAs) and cancellations. As a result, practices were required to reduce the number of routine check-ups by cancelling patients from the governments list of vulnerable groups and offering a cancelation to anyone who still wished to attend. This reduced the need to travel and to have close contact with people in practices and consultation rooms. To ensure the eye health needs for patients, all urgent and essential eye care would continue to be provided and prioritised by all optometry practices.

To ensure business continuity, NHS optometry practices were provided with confirmation of financial support during the first three-month period of the pandemic. All practices would receive an average monthly payment based upon their historical NHS activity over the previous three-year period (General Ophthalmic Services (GOS), Eye Health Examination Wales (EHEW) and Low Vision Service Wales (LVSW)) from April to June 2020. This ensured optometry practices contracted to provide NHS Wales’ services were able to maintain their cash flow and provide their optometry teams with protected income. Private optometry practices and private income of mixed practices were able to access wider Welsh Government support for other self-employed businesses.

On 19 March 2020, a further letter was issued to the optometry profession. The aim was to prevent any unnecessary clinical activity, ensure that aerosol generating procedures (AGPs) ceased in primary care and patients were referred to ophthalmology departments thereby minimising the risks of virus transmission associated with AGP procedures.

Background

As we move away from lockdown and consider an easing of the current measures associated with the Covid19 pandemic, plans to re-open optometry practices safely, for both patients and the workforce, need to be put in place.

The current situation in Wales is as follows:

  • all unnecessary patient contact stopped.
  • if urgent or essential primary care optometry eye care is needed, NHS and private patients contact their optometrist and are referred to one of the 87 optometry practices aligned to the 64 clusters across Wales
  • aerosol generating procedures (AGPs) are only undertaken at ‘red sites’ (secondary care rapid access units or community emergency centre aligned to dental hubs with the appropriate process and equipment in place)
  • recommended personal protective equipment (PPE) e.g. disposable gloves, disposable aprons, fluid resistant face masks and eye protection, are available to optometry practices that remain open

Activity in optometry practices in Wales to date (data collection system operational since 17/04/2020)

Number of practices open: 88

Total patients: 7649

Type of consultation

Type of consultation Number Percentage
Telephone or video consultation 2,620 34.3%
In practice consultation 4,787 62.6%
Home visit 57 0.7%
Other 185 2.4%

Referrals from doctors

Referrals from doctors Number Percentage
Referred from GP 660 8.6%
Referred from opthalmologist 184 2.4%

Patients with urgent eye care (1st presentation)

3,654

47.8%

Of patients presenting for urgent care

Of patients presenting for urgent care Number Percentage
Medication advised/sold/pharmacy 1,044 28.6%
Medication prescribed 367 10.0%
Referral HES urgent/emergency 438 12.0%
Referral GP 381 10.4%

As outlined above, there is now a need to plan for the period from June/July 2020 to March 2021. The transition to resumption of optometry care requires a phased approach. A key consideration is to provide business continuity, given the impact of restricted numbers and social distancing measures and safety of the workforce and patients to prevent disease transmission, which has impacted greatly on the provision of NHS optometry services. However, the response must also consider how we deliver to our policy objectives: encouraging access for all, evidence-based prevention and clinical care based on need, delivered by the most appropriate member of the eye care workforce team.

Wider opening of optometry services will depend on maintaining the reduction in community transmission of COVID-19 and in time, the development of an effective vaccination programme. The wider use of video consultation to enable remote diagnosis and self-care as well as reducing face-to-face examination time and support a new model of service delivery will be essential. Equally, the continued supply of appropriate PPE to optometry practices is important, alongside community testing and a greater understanding of transmission, both in the primary and community care optometry settings. It is likely significant levels of unmet need from delayed eye care will present, therefore priorities for available capacity in resumed optometry services will need to be set and agreed. Consideration must also be given to the future eye care needs of vulnerable groups (including those who are currently being shielded).

There is a need to ensure the sustainability of the optometry profession throughout this period, both in clinical and economic terms.

Analysis for re-introduction of Services

Amber Phase

1. General considerations

In the amber phase immediately post lockdown, some practices may not re-open immediately as they or those they live with are in vulnerable groups, or are ill/self isolating.

2. Social distancing measures

It is unlikely social distancing measures will be eased completely in the immediate phase following lockdown. As such, practices will have to ensure social distancing can be maintained. Measures, as currently seen in supermarkets will need to be followed which will include restricting the number of patients in a practice at any one time, ensuring 2 metre distance between patients in all areas, reception, diagnostics and general practice areas.

3. Clinical

Optometrists traditionally spend a considerable amount of time in close contact with patients (less than 1M). During the current “Red Phase” of delivering urgent and essential eye care, certain areas of practice have changed to ensure the face-to-face consultation time with patients is reduced. This has included telephone triage of all patients to ensure only patients asymptomatic of Covid-19 are seen and the use of telephone and video consultations where safe to do so. To continue to reduce contact time during examinations many of these practice changes will need to continue, and be embedded into practice for long-term benefits.

  1. Triage of patients to ensure only asymptomatic patients are seen in practice.
  2. History and symptoms and other relevant clinical areas such as dispensing considerations to be conducted by telephone/video.
  3. Video consultations for some presentations (in line with College of Optometry guidance) can be used.
  4. Where posting spectacles or contact lenses to patients is not an option, appointments for collections will be required to ensure numbers in practices can be controlled and monitored effectively.

4. Infection control measures

The transmission of COVID-19 is thought to occur mainly through respiratory droplets generated by coughing and sneezing, and through contact with contaminated surfaces. The predominant modes of transmission are assumed to be droplet and contact. This is consistent with a recent review of modes of transmission of COVID-19 by the World Health Organisation (WHO).

Standard Infection Control Precautions (SICPs) are to be used by all staff, in all care settings, at all times, for all patients whether infection is known to be present or not, to ensure the safety of those being cared for, staff and visitors in the care environment.

As with social distancing measures, effective infection control measures are required by practices. This is divided into several areas for consideration, clinical and diagnostic examinations, dispensing of spectacles, general practice considerations.

  • Wipe down and cleaning of instruments between patients, including slit lamps (attention to both sides of breath shields), trial frames, occluders, reading charts, amsler charts etc. Door handles, light switches, patient and practitioner touch points. Normal infection control procedures required.
  • Infection control for diagnostic instruments in pre-screening. Visual field instruments, retinal imaging instruments, OCT, focimeters etc.
  • Non-contact tonometry; current clinical advice is not to perform due to the aerosol generating aspects. Further advice will be required from the College of Optometrists before recommendations can be made. Similarly, consideration needs to be given to what stage the use of Alger brush in foreign body removal is re-introduced.

Dispensing

  • Social distancing whilst dispensing.
  • Disinfection of frames following patients trying on. Frame rules and dispensing aids disinfection.

General Practice

Regular infection control around door handles and surfaces following contact by patients and practice staff.

Personal Protective Equipment (PPE)

Clear guidance has been issued for the use of PPE for examining patients in optometric practice (on GOV.UK). During the current “Red phase”, optometry practices that have remained open have received a supply of PPE. The use of PPE will need to be supplied and continue during subsequent phases and be embedded routinely into clinical examinations for all optometric practice.

Additionally PPE will be required for dispensing opticians (DO’s) and optometric assistants (OA’s) when taking measurements for dispensing of spectacles, and according to government guidance may also be required for some reception staff.

Appendix 1

Recommendations for Amber Stage (Appendix 1)

  • All practices available to open.
  • General Ophthalmic services provided.
  • Eye Health Examination services provided.
  • Low Vision service provided (with careful consideration for this vulnerable group of patients).
  • Video consultation offered where appropriate as first option.
  • Local Health Board commissioned services increased to support ophthalmology capacity and demand issues.
  • Acute domiciliary commissioned service to continue.
  • Routine domiciliary service to remain suspended.
  • Average NHS payment to remain for practices that remain open and those that closed due to Covid-19 related health issues (self-isolation/government imposed lockdown e.g. domiciliary companies). All practices must provide full NHS services to include GOS (sights tests, provision of optical appliances and repairs/replacements), EHEW and LVSW services (where applicable) as part of the average NHS payment.
  • Data collection of all patient episodes to continue as a mandatory requirement for average NHS payment.
  • PPE supplied to open practices.
  • All practices to complete the National Wales Shared Services Partnership self-certification process for opening, including the Covid-19 training available through the WOPEC website.

Red

Indicators for timing

  • Government instigated lockdown 17 March with specific strict social distancing measures.

Practices open

  • Cluster Hubs established in all 7 health boards; 87 practices open 7 April.

Primary Care Activity and Service Provision

  • 15% of pre-Covid-19 activity; aligned to social distancing measures.
  • GOS: Urgent and essential only.
  • EHEW: Urgent and essential only.
  • LVSW: No service.
  • DESW: Routine screening suspended.
  • Commissioned service for retinopathy check in pregnant patients.
  • Children’s School Screening Service Wales ) CSSSW: No services
  • Domiciliary all services: DEECS only where commissioned

Welsh Government agreed finance package of support

  • Adjusted payment for all practices open in Cluster Hubs - 125% average NHS payment.
  • Adjusted payments are based on ‘average’ of historical GOS, EHEW and LVSW payments for all practices.
  • UK Government wide furlough arrangement in place for workforce, where appropriate.

PPE NHS provision

  • To all “Open” practices aligned to primary care clusters; delivery completed April.

Secondary Care Services Provided in Primary Care Optometry

  • Essential only.
  • Glaucoma extended referral refinement data capture
  • Post cataract care 
  • wet-AMD, ODTC
  • Any safe and effective urgently instigated pathway in response to identified need within health boards during COVID

Amber

Indicators for timing

  • Welsh Government decision taken at a point following easing of lockdown measures, with strict social distancing measures 
  • reopening [date tbc]

Practices open

  • Cluster Hubs 90 practices.
  • All practices open
  • Date: xxx

Primary Care Activity and Service Provision

  • 60% of anticipated post Covid-19 normal activity; aligned to social distancing measures
  • GOS: All services
  • EHEW: All services
  • LVSW: All services
  • DESW: No service
  • CSSSW: No service
  • Domiciliary: DEECS only where commissioned

Welsh Government agreed finance package of support

  • Adjusted payment for all open practices aligned to Clusters - 100% average NHS payment

PPE NHS provision

  • To all Cluster aligned practices; delivery completion date tbc

Secondary Care Services Provided in Primary Care Optometry

  • EHEW pathways.
  • As commissioned by health boards:
    • Glaucoma referral refinement data capture Glaucoma ODTC / Glaucoma stable follow up with virtual clinic
    • wet-AMD, ODTC
    • Cataract Enhanced Referral
    • Naevus monitoring
    • Continuation of pathways developed within health boards during COVID. This need will continue due to backlog created during COVID.

Green

Indicators for timing

  • Welsh government decision taken at a point where it is considered that no significant further relaxation to social distancing measures is foreseeable.
  • [date tbc] - ‘new normal’

Practices open

  • All practices should be open; [xyz number] practices open Date : xxx

Primary Care Activity and Service Provision

  • 100% of anticipated normal post Covid-19 activity
  • GOS: All services
  • EHEW: All services
  • LVSW: All services
  • DESW: All services
  • CSSSW: All services
  • Domiciliary: All services

Welsh Government agreed finance package of support

  • Adjusted payment for all practices open or closed – revoked.
  • UK Government wide furlough arrangement revoked.
  • Normal activity, service provision and payments resume, adhering to Regulations, Legislative Directions and Welsh Health Circular guidance; in line with GOS, EHEW, LVSW, DESW and CSSS service specification/ manual and standard operating procedures.

PPE NHS provision

  • To all Cluster aligned practices; pathway agreed for all practices to replenish PPE stock as required.

Secondary Care Services Provided in Primary Care Optometry

  • EHEW Pathways:
    • Post cataract care
  • OHT & Glaucoma Suspect
  • As commissioned by health boards:
    • Glaucoma referral refinement data capture
    • Glaucoma ODTC / Glaucoma stable follow up with virtual clinic
    • wet- AMD, ODTC
    • Cataract Enhanced Referral
    • Naevus monitoring
  • Continuation of pathways developed during COVID.

Share this page