Coming Up Short: The State Of Ophthalmology in the UK

With health care systems in the UK still dealing with the aftermath of the COVID-19 pandemic on top of chronic staff shortages and underfunding, ophthalmology has been through some seismic changes. To find out more about the state of the field in the UK, we sat down with outgoing president of the Royal College of Ophthalmology, Bernie Chang, to discuss the recent RCOphth Workforce Census 2022, how UK ophthalmology has changed, and some of the serious problems that need to be faced.

From the 2018 to 2022 workforce censuses, how has UK ophthalmology changed?
 

Many of the key issues identified in 2018 – for example, workforce shortages and high reliance on locums – remain the same today. A particularly sobering discovery in the 2022 census is that 76 percent of NHS ophthalmology units don’t have enough consultants to meet current patient demand. Compared with 2018, we have over 200,000 more referred patients waiting to see an ophthalmologist today. These growing strains on the system are something all ophthalmologists will have noticed in recent years. Clearly, COVID-19 added to these pressures, but the key reason for these worrying backlogs is rising patient need, which has simply not been matched with increased service capacity.

One notable change in England is the growing role of independent sector providers delivering NHS cataract procedures (from 20 percent in 2018 to around 50 percent in 2023). The pandemic is a big part of this story, given that independent sector capacity was commissioned when NHS services were unavailable, but the trend has continued beyond that immediate crisis. And though this capacity has helped bring down cataract waiting lists, there are concerns that the knock-on effects are now hampering rather than helping comprehensive NHS ophthalmology services.

What is the current and projected need for ophthalmologists in the UK?
 

In 2021, Public Health England highlighted that England had about 2.5 consultant ophthalmologists per 100,000 population, well below the recommended 3–3.5 level needed. Achieving that minimum recommendation would require an additional 250 consultant ophthalmologists today. Given our rapidly aging society, if no action is taken, that shortfall will quickly become much more severe. It’s impact will be different geographically as well which can lead to increased inequalities of care. The census shows that, recruiting and retaining staff is proving difficult; 52 percent of eye units found it more difficult to recruit consultants compared with the previous 12 months, while 67 percent found it harder to retain consultants. And though 84 percent of units need at least one additional consultant post to meet current patient demand, only 40 percent of these units are currently advertising for consultants with a lack of ophthalmologists to fill these consultant roles.

We therefore need to increase the training pipeline. It’s not a lack of interest – ophthalmology is one of the most over-subscribed training programs. With funding for more training places, we could tackle some of these gaps. Increased training places would need to be combined with more clinic and theater space, more trainers and more supervisors – all to ensure ophthalmologists in training are properly supported with the right case mix.

We are also clear that eye care is not delivered only by doctors and that supporting the whole multidisciplinary eye care team – optometrists, orthoptists, ophthalmic nurses, technicians and potentially physician associates – to perform to the top of their license is essential for creating more capacity. Local-level funding mechanisms will be crucial in making this happen – the Royal College’s Ophthalmic Practitioner Training Programme is one such example.

Has ophthalmology been particularly hard hit COVID-19 disruptions? What is needed in the short and long term to clear the backlog?
 

When the pandemic hit, we saw a 40 percent fall in cataract procedures and a 38 percent fall in those attending ophthalmology outpatients for the first time. There was a huge amount of innovation to adapt to the situation – surgical hubs, virtual digital clinics, the increased integration of primary care optometry to manage high-risk patients, and more besides – but we’re still faced with a very long backlog of care. In the short term, we need to see ophthalmology services incorporated into community diagnostic centers so that we can focus on bringing down the backlog. This endeavor would be facilitated by the recruitment of technicians and other non-medical staff to support diagnostic data collection. Our census also uncovered some frustrating roadblocks, such as lack of clinic and theater space. NHS organizations need to ensure they are providing ophthalmology units with the appropriate space, configured to support high-flow ophthalmic pathways.

Delivering future services more efficiently will also require technological improvements. We need a national Electronic Eye Care Referral System (EERS) to be developed, allowing optometrists to directly refer patients to ophthalmology. An EERS would also facilitate shared imaging standards across primary and secondary care, enabling high volume, efficient patient data sharing. Our world renowned National Ophthalmology Database for cataract surgery will also help to improve the delivery of care. It collects performance data and has driven improved complication rates to less than 0.91 percent of all surgeons.

Why are staff leaving NHS ophthalmology work?
 

Retaining ophthalmologists is a big challenge facing the NHS. Sixty-seven percent found it more difficult to retain consultants compared with the previous 12 months. Key reasons cited by ophthalmologists for leaving were burnout and the impact of working in under-resourced departments. For those leaving for reasons other than retirement, 76 percent cited wanting a better work/life balance and 50 percent pointed to stress as a key factor. We can see from recent industrial action the pressure that many staff across the NHS feel, and so private practice, locum work or moving overseas to work are becoming more attractive for ophthalmologists.

How are hospitals coping with the shortage of ophthalmology consultants? And what are the problems with an overuse or overdependence on locums?
 

Reliance on locums is deeply ingrained in ophthalmology. Almost two thirds of units are using locums to fill consultant vacancies, with 57 percent using locums for over 12 months to fill these posts. This dependence can create challenges in terms of the continuity of care delivered, and it also comes with cost implications for the NHS.

One way in which hospital eye services have responded to shortages of ophthalmologists is to expand the responsibilities of other professions delivering eye care. Empowering all professions to work to the top of their medical license is something RCOphth strongly supports, including through our Ophthalmic Practitioner Training Programme, which encourages local training to standards developed by the RCOphth. This can help free up ophthalmologist time to manage and diagnose the most complex cases.

For individuals at the beginning of their ophthalmology careers, what are the biggest challenges identified by the census – and what are RCOphth’s recommendations?
 

It was reassuring to find that ophthalmologists in training are generally happy with their training experience and plan to become NHS consultants. But there is a growing issue about access to surgical training opportunities that is evident in both our census and recent GMC surveys. The census found that 74 percent of trainees would like to be doing more surgery. This backs up data from GMC’s National Training Survey, which last year found that 42 percent of ophthalmology trainees had not been able to compensate for the post-pandemic loss of training opportunities. Worryingly, this is far higher than the 23 percent figure across all specialties.

The growing role played by independent sector providers in England appears to be an important factor in fewer training opportunities being available to ophthalmology trainees. GMC’s survey found that of the three quarters who needed to access training opportunities in the independent sector, 86 percent disagreed that they were easily able to access these (only 6 percent agreed). This has been improving as the RCOphth is working hard to ensure that wherever NHS surgery is delivered, there are appropriate training opportunities available because it is absolutely crucial in enabling us to effectively train the next generation of ophthalmologists.

According to the survey, trainees are keen to do more research and specialist doctors are keen to do more surgery. What’s currently limiting access to these opportunities?
 

It’s really encouraging that ophthalmologists in training are keen to be more involved in research, which will ultimately help us to improve patient care. Note that 62 percent are currently research-active, but 54 percent would like to be more involved. Other service commitments are likely to be limiting the capacity they have to do more research, but NHS organizations can help by creating a stronger research culture, which should include providing protected research time in job planning.

The census also found that over half of doctors would like to perform more surgery. Analyzing responses to the census, there is definitely a clear desire among specialist doctors for greater recognition and simpler routes for progression. And that’s something we are certainly keen to support. We hope the work RCOphth is doing, led by the GMC to reform the Certificate of Eligibility for Specialist Registration (CESR) process will help achieve these goals.

According to the survey, how is the huge growth of the independent sector perceived?
 

Views are mixed on the impact of the growth of independent sector providers in ophthalmology, but there are clearly concerns; 58 percent of NHS ophthalmology units say the impact of independent sector providers on patient care and services in their unit has been negative, while 38 percent say it has been positive. These developments primarily affect England rather than the other UK nations, and the impact is variable across different parts of England. Units in the East and North West of England are most likely to be concerned.

In light of the survey, what message would you like to share?
 

Ophthalmologists should be proud of what they have achieved in the last few years – I am struck by how they have adapted and innovated in the most difficult of circumstances to deliver high quality patient care. But continuing to work in such stressful environments is not tenable in the long term, and we know more ophthalmologists in the UK are considering leaving the profession under this strain. RCOphth will be working with policymakers to do all we can to address the significant challenges faced by ophthalmology services across the UK. I would also urge all ophthalmologists who are members of the College to get involved in our work – whether that’s developing clinical guidance, training, undertaking research, or being an examiner – to shape the profession for the future. Ultimately, we are here to call attention to the challenges the profession and our patients face, and work collaboratively to find solutions. Your contribution is essential to that endeavor. Ophthalmology has never been higher on the agenda of policymakers, and we must seize the opportunity to make a difference and improve ophthalmology care for the long term.