NHS sight tests include unevaluated screening examinations that lead to wasteBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2084 (Published 19 March 2014) Cite this as: BMJ 2014;348:g2084
- Michael Clarke, consultant ophthalmologist, Newcastle Eye Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, and reader, Institute of Neuroscience, Newcastle University
Ophthalmology receives more NHS outpatient referrals than any other specialty apart from trauma and orthopaedics.1 There are reasons why this should be the case: eye disease is a common accompaniment to old age and is associated with systemic diseases, such as diabetes, which are rising in prevalence. A more significant reason lies in the framework under which opticians operate and are regulated in the United Kingdom.
Under section 26 of the Opticians Act, revised in 1989,2 an optician carrying out an NHS sight test has “to perform such examinations of the eye for the purpose of detecting injury, disease or abnormality in the eye” and “immediately following the test to give the person whose sight he has tested a written statement—(i) that he has carried out the examinations that the regulations require, and (ii) that he is or (as the case may be) is not referring him to a registered medical practitioner.”
This has been interpreted to mean that an optician or optometrist has a responsibility to refer to a medical practitioner any patient in whom an ocular abnormality is detected on examination during an NHS sight test. Historically, the examination concerned used direct ophthalmoscopy alone. In the past 50 years, however, other examinations and tests have been bolted on to the NHS sight test, starting with the testing of intraocular pressures, followed by visual field testing, and latterly colour fundus photography and optical coherence tomography, usually offered for an additional fee.
Despite these tests and examinations consuming a considerable amount of NHS resources, such so called “eye health checks”3 have never been subject to the scrutiny of the UK National Screening Committee. But the checks do represent a form of screening that is limited to people who access NHS sight tests, and for which consent has not been sought—either from individuals or from society as a whole.
Who benefits? Clearly some patients with asymptomatic disease can benefit from early detection of their condition, but there are many false positive referrals, with all the unnecessary anxiety and societal cost that are associated with unregulated screening. Studies of telemedicine and referral refinement in ophthalmology have estimated that this group constitutes about 30% of all new ophthalmology referrals.4
Although such referrals contribute to the healthy private practices enjoyed by many ophthalmologists, and contribute to the bottom line for chief executives of NHS trusts, there is, on the face of it, little gain in this system for the opticians themselves. In contrast to the situation in Scotland, the fee for the sight test in England has not changed for some years, and it makes little sense to buy expensive equipment to perform additional testing that is nowhere mandated. However, opticians are businesspeople, and to market their practice and sell the spectacles on which their businesses depend, they need to be seen to be keeping up with the times.
Opticians are unconstrained by any disincentives to refer patients; in fact they have a legal obligation to do so, but where is general practice in all this? General practitioners, with little formal training in ophthalmology, and intimidated by the technology and terminology in use, may feel unable to exercise their usual gatekeeping function for patients referred by opticians, and rubber stamp referrals to hospital eye services.5 Hospital services may then struggle to cope with demand, particularly given other developments, such as advances in treatment for age related macular degeneration that require patients to return every month for intraocular injections.
Hospital eye services have received considerable investment in the past 15 years, but that era is at an end, and the focus now is on reducing demand, on care closer to home, and on better referral. Opticians, being well organised and politically savvy, have devised solutions for clinical commissioning groups. These solutions are being deployed through local eye health networks, organisations under the umbrella of NHS England that have replaced the optical advisers to primary care trusts. The solutions involve paying opticians more to triage the unnecessary referrals they have initiated. Many ophthalmologists doubt whether these solutions will save money, despite enthusiastic advocacy by optometrists.
Where does this leave the care of patients with eye and visual disorders? Perhaps the clue is in the similarity of the brand name “eye health” to “oral health.” The future for these patients may lie in a mixture of NHS and private care such as now exists for dentistry.
The NHS must find a solution to the waste generated by unnecessary referrals from unregulated, scattergun screening of patients attending for NHS sight tests. Those solutions are not going to come from opticians or the “eye health” community. It is time for ophthalmologists to get up from their slit lamps, step into the light, engage with general practitioners and commissioners, and demand that ophthalmology is subject to the same evidential requirements as other medical specialties.
Cite this as: BMJ 2014;348:g2084
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: I am clinical director of an NHS eye department.
Provenance and peer review: Not commissioned; not externally peer reviewed.