Few fears match that of going blind. We value sight more than any other sense and the loss of it is dreaded more than other long-term health conditions such as dementia, heart disease, Parkinson’s disease or having to use a wheelchair, research by the Royal National Institute of Blind 
People (RNIB) has found.
But it is a fear that has to be faced by an ever-growing number of people as the population ages. The numbers living with some degree of sight loss are expected to double from two to four million by 2050. The longer we live the more likely we are to suffer sight loss, with a fifth of over-75s handicapped by it to some degree.
Despite this, sight loss and eye health have a lower priority in health funding than lots of other conditions. “Because you don’t die from it, it tends to be trumped by cardiovascular disease and cancer, even in areas where they assess the need and eyecare scores quite highly,” says Clara Eaglen, eye health campaigns manager at the RNIB.
Call to Action
A year ago, NHS England raised expectations for eyecare with a Call to Action, a report that outlined the issues and called for responses to a series of questions. Numerous bodies dutifully responded by the September 2014 deadline in the hope that this might be a chance for eyecare to enjoy a moment in the sun.
The key now is to learn from good examples and replicate them at scale where it makes sense to do so
What followed was a disappointment. NHS England adopted the policy of localism outlined in its Five-Year Forward View and has never responded directly to the ideas its Call to Action provoked. The idea of a National Director for Eyecare, strongly supported by many respondents, fell on deaf ears. “It’s a bit of a shame,” says Ms Eaglen.
NHS England says: “All key feedback put forward by various parties has been incorporated across the fundamental elements of the Five-Year Forward View and the NHS England Business Plan, and shared with regional eyecare teams to help with the production of local business.” In plain English, this means that local teams have been told to pick up the baton and run with it.
Fragmented system
Regional eyecare teams are one of a plethora of advisory, consultative and executive bodies entrusted with our sight. Few services in the NHS are as fragmented. NHS England is responsible for sight tests, but if anything slightly complicated emerges, such as the need for follow-up tests for glaucoma, it’s the job of the 200-plus clinical commissioning groups (CCGs) to pay. While 90 per cent of hospital referrals to ophthalmology departments originate with optometrists, the people who do eye tests and mostly operate out of optical practices on the high street, they seldom hear the outcome as there is no systematic system for feedback.
GPs deal with minor eye complaints, such as conjunctivitis, but anything more complicated has to be referred to a hospital where services are “chaotic and rushed” to quote a recent report by the Eye Health Network for London.
David Parkins, president of the College of Optometrists, believes that change is finally happening. He chairs the Clinical Council for Eye Health Commissioning for England, a body set up to provide leadership and help co-ordinate the patchwork quilt of overlapping responsibilities. “Given the current capacity issues in ophthalmology services and pressures on general practice, the status quo is not sustainable,” he says. “The key now is to learn from good examples and replicate them at scale where it makes sense to do so. We cannot afford to keep reinventing the wheel.”
Cash pressures
Eye health services cost the NHS in England around £2.3 billion a year, £500 million of which is spent on sight tests and £1.4 billion on elective care in hospitals. The most tractable of eye conditions is cataract, which can be corrected by surgery that costs under £1,000 per eye. It’s the commonest operation carried out by the NHS and gets good results. But cash pressures are mounting.
There is an almost threefold variation in the number of operations carried out in different areas of England, which cannot possibly be explained by a difference in patient numbers. Half of CCGs impose thresholds on who can have an operation and one in three make no provision for treating the second eye. The Royal College of Ophthalmologists’ commissioning guide to cataract surgery, published in February, reported that an astonishing 90 per cent of commissioning policies contained criteria that followed “neither national guidance nor scientific evidence”.
Waiting times, which were slashed from two years in 2000 to four months in 2008, are creeping up again. And while waiting for cataract surgery doesn’t put eyesight at risk, delays in glaucoma appointments may. The condition is caused by pressure in the eye and affects around 2 per cent of the population. It causes no pain or symptoms so needs to be detected in eye tests and can then be controlled. But if delays occur, the opportunity may be lost.
A question in the Welsh Assembly revealed that in 2014 there were at least 26 serious incidents of people suffering deterioration of eyesight while on an NHS waiting list.
Treatment for wet age-related macular degeneration is one of the success stories of the past decade. But many CCGs believe more could be done. In February, 120 of them joined in a call to allow the replacement of Lucentis, a drug that costs the NHS £245 million a year, with the similar, but much cheaper, Avastin. However, Avastin is unlicensed for use in the eye and, although trials show it is roughly equivalent in efficacy, regulators in the UK are reluctant to give the green light to off-label or unlicensed use.
