Impact case study database

The research conducted as part of the ESEP has provided a solid evidence base for the clinical safety and cost-effectiveness of enhanced services provided by community optometrists. The outputs from the ESEP, and previous research by the City team investigating effectiveness and refinement of glaucoma referral schemes, have informed commissioning guidance from NHS England, the College of Optometrists and the Royal College of Ophthalmologists, and NHS Improvement [5.1]. As a result, these outputs have played a major role in building the business case for Local Optical Committees (LOCs) to influence the decisions of Clinical Commissioning Groups (CCGs) to adopt MECS and GRFS pathways. The director of commissioning strategy for South East London CCG has commented “ *The CCG and the City team have directly supported more than 20 CCGs to implement their own schemes, but know that the work that we did has become almost standard practice for the whole of the NHS, and has been cited as the exemplar model by the Royal National Institute of Blind People.*” [5.2].

Minor Eye Conditions Services

The percentage of LOC regions in England that operate a MECS has increased from 55% to 71% since 2015. Over the same period an additional 4,000 optometrists have undertaken MECS accreditation. The commissioning of MECS significantly impacts referral rates from primary to secondary care, reducing the 1.7 million first attendances at ophthalmology outpatient departments by at least 10%. This is the equivalent of 170,000 HES appointments, representing net savings of GBP5,500,000.

In 2017, the Royal National Institute of Blind People, in partnership with Specsavers, the largest chain of optical practices in the UK, hosted a series of policy roundtable discussions at which a range of experts including patients, health professionals and commissioners came together to explore how improving delivery in eye care services could help increase capacity. Research from the ESEP was used as evidence for the clinical effectiveness and cost-effectiveness of MECS [5.3]. In 2016, Specsavers announced that more than 2000 of its optometrist employees have successfully become accredited to offer MECS in England [5.4], a strategic decision underpinned by our research [5.5].

Community-based Glaucoma Referral Filtering Services

Our research has also demonstrated the clinical effectiveness and cost-effectiveness of glaucoma referral filtering services (GRFS) in reducing referrals and freeing capacity in glaucoma clinics. The NICE guideline committee for glaucoma, which included ESEP team member Fenerty, recommended that ‘people planning eye care services should consider commissioning referral-filtering services (for example, repeat measures, enhanced case-finding, or referral refinement) for chronic open angle glaucoma and related conditions’ [5.6]. Commissioning guidance has also noted “ Independent monitoring of patients with a diagnosis of glaucoma (which must be established by a consultant ophthalmologist) is permitted and encouraged by NICE for those optometrists and other HCPs with training, skills and experience to the level of the CoO [College of Optometrists] Professional Diploma in Glaucoma” [5.7]. The NICE recommendation was informed by the findings of ESEP and previous research on referral refinement by members of the City team.

Clinical Management Guidelines

Underpinned by research over the past 10 years in priority areas of eye care, Lawrenson and Buckley have been engaged by the College of Optometrists through academic consultancy to lead on the development of Clinical Management Guidelines (CMGs) for the diagnosis and management of a range of eye conditions that present with varying frequency in primary and first contact care. A comprehensive process of identifying and rating the quality of evidence on the management of over 60 conditions and making specific treatment recommendations underpins each guideline (updated biennially) [5.8]. The Commission for Human Medicines (CHM) used the CMGs in their consideration of the proposal to allow optometrists to train as Independent Prescribers. They were also instrumental in the decision by the CHM to recommend that suitably qualified optometrist independent prescribers could prescribe any licensed medicine (for conditions affecting the eye, and the tissues surrounding the eye, within their recognised area of expertise and competence). The CMGs therefore have significant ongoing impact because they continue to inform the content of the Common Final Assessment for Independent Prescribing, the accreditation assessment conducted by the College of Optometrists for entry into the specialist register of therapeutic prescribers [5.9]. There are now over 500 practising optometrist independent prescribers working in specialist hospital settings and in the community. The CMG pages account for 22% of all unique page views to the College of Optometrists’ website (2,284,305 unique page views to the website and 502,387 to CMG pages in the year 2018-19).

The CMGs are also written into the service specifications for MECS pathways by the Local Optical Committee Support Unit (LOCSU), the Northern Ireland Primary Eyecare Assessment and Referral Scheme (PEARS) and, more recently, the national service framework for COVID-19 Urgent Eyecare Services (CUES) [5.10]. CUES acted as urgent eye care community hubs during the coronavirus pandemic. The quality of the guidelines has been recognised, and they inform the management of eye conditions by optometrists and other primary healthcare professionals e.g. CMGs are referenced in BMJ Evidence and NICE Clinical Knowledge Summaries (for GPs) [5.11].