Introduction

Providing sufficient capacity for glaucoma care presents challenges. Approximately 3.54% of adults aged 40–80 worldwide have open angle glaucoma [1] and with an ever-aging population, numbers of UK cases are set to rise [2]. A report by the Healthcare Safety Investigation Branch concluded there is insufficient capacity to meet demand [3], with the pandemic subsequently escalating concerns [4, 5]. In addition to capacity challenges, there have been recent changes in glaucoma care recommendations.

The role of optometrists in glaucoma within primary and secondary care has been well described [6,7,8]. In 2009, the first National Institute for Health and Care Excellence (NICE) glaucoma guidance was published [9], making recommendations about organisation of care, including the role of optometrists and other eye health professionals, and appropriate qualifications to work within different levels of care. The 2017 NICE guidance stated there was a requirement for optometrists and other health professionals to have both a glaucoma-related and independent prescribing (IP) qualification to make management decisions regarding glaucoma treatment [10]. The College of Optometrists’ and Ophthalmic Practitioner Training (OPT) programme both offer 3-tiered higher qualifications system mapped to different levels of care provision [11, 12]. Although NICE and commissioning guidance documents specified the importance of additional qualifications for optometrists, questions arise whether the number and distribution of optometrists with qualifications in glaucoma is sufficient to meet demand [13]. Within the Hospital Eye Service (HES), comparative national scope of practice surveys showed glaucoma was the leading extended role (88% of all units involved in glaucoma care in 2020) [14]. Data from this survey also showed a large increase in optometrists delivering laser, with 14 units (16%) with optometrists delivering SLT in 2020, up from 1 unit (1%) in 2015 [15].

In 2022, the NICE glaucoma guidance was updated in response to the LiGHT trial [16], incorporating the recommendation to offer selective laser trabeculoplasty (SLT) as first-line treatment for newly diagnosed patients with open angle glaucoma and ocular hypertension, acknowledging the role optometrists, amongst other health professionals, may play in delivering SLT [17]. Whilst many studies have examined safety and clinical effectiveness of optometrists in glaucoma care [18,19,20,21], despite the marked increase in optometrists’ involvement, there is a paucity of qualitative research evaluating enablers and barriers for delivering care, and particularly across a multi-stakeholder opinion base.

The overall aims of this study are to investigate qualitatively, and from a multi-stakeholder perspective:

  • Whether optometric glaucoma care is accepted as an effective alternative to traditional models by patients, providers, and other stakeholders.

  • What contextual factors impact upon the development, outcome, and sustainability of glaucoma care by optometrists.

Materials and methods

Method of recruitment

Patients were recruited from glaucoma clinic attendees at Manchester Royal Eye Hospital (MREH) and nationally via a Glaucoma UK registrant database. Patients attending MREH clinics during September 2021 were approached during or following their appointment. Patients registered on the Glaucoma UK database were invited via an email link. Optometrists were invited to participate during a College of Optometrists’ glaucoma-related lecture, as well as a further purposive sample from optometrists known by the research team to be involved in glaucoma roles. Ophthalmologists and other stakeholders involved in glaucoma services were recruited via direct contact. Representation was sought from across all 4 UK home nations.

Ethical approval and Patient and Participant Involvement (PPI)

Ethical approval was granted for this project (IRAS reference 276641). Patient and Public Involvement was sought from a MREH glaucoma patient to review the protocol, participant information sheets, and interview/focus group topic guides, as developed by the research team. Informed consent was taken from all participants.

Inclusion and exclusion criteria

All participants needed to be over 18 years old, able to communicate in English (or have availability of an interpreter) and be able to provide informed consent.

Patients needed to attend a glaucoma clinic, clinicians had to be involved in delivering glaucoma-related care, commissioners and other stakeholders held responsibility for planning or delivering glaucoma-related care.

Interview and focus group conduct and data analysis

Interviews and focus groups were conducted via password protected recorded video meetings and transcribed anonymously. Whilst topic guides (provided in supplementary material) were available for those conducting interviews and focus groups to prompt around defined topic areas, participants were encouraged to discuss other topics, with interviewers probing unanticipated areas raised. Data was analysed using the framework method for analysis of qualitative data [22]. Interviews and focus groups were first analysed separately, and initial themes identified. Transcripts were then analysed again where relationships and evolving, interlinked themes were identified within NVivo 12.

Results

Recruitment

There were 38 participants, the breakdown of which is summarised in Table 1.

Table 1 Summary of recruitment including: participant background, method of interview, sex and location within the UK.
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We recruited 7 patients from MREH and 8 from the Glaucoma UK database. Optometrists were employed in a variety of settings including primary care (main employment for 5 participants), secondary care (5 participants), community ophthalmology services (1 participant), and postgraduate optometry education or professional development (3 participants). Regarding commissioning and other stakeholders, one participant was involved in ophthalmology service design nationally (optometrist by profession), one was involved in commissioning in Northwest England and one in Southwest England. All Consultant Ophthalmologists were glaucoma specialists. The one-to-one interviews were 33–67 minutes and the focus groups 56–80 minutes duration.

Themes

The following section outlines key themes emerging from analysed interview data. Associated, numbered quotations from participants can be found in Tables 2 to 5.

Table 2 Participant quotations regarding enablers and drivers; challenges and barriers.
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Table 3 Participant quotations regarding training, education and higher qualifications; level of professional practice; laser.
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Table 4 Participant quotations regarding the role of other non-medical eye health professionals; commissioning, development of local and national pathways; COVID 19; looking to the future.
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Table 5 Participant quotations regarding patient experience.
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Enablers and drivers

Optometrists were driven to work in glaucoma clinics due to clinical interest, motivation to support overburdened clinics, and professional satisfaction [1.1]. Others expressed they found it rewarding to progress their clinical skills through work in glaucoma clinics [1.2], while being able to offer continuity of care with patients was also mentioned favourably [1.3]. That said, an optometrist who later became involved in developing care pathways stated they felt let down following their initial qualification, believing they could make greater contributions [1.4].

Having optometrists delivering glaucoma-related care in the community due to demand and ease of access for patients was noted as a driver by ophthalmologists and optometrists [1.5, 1.6]. Mutual respect between professions was reported as important in successful service implementations [1.7, 1.8]. Many responsible for training optometrists, including clinical academics and ophthalmologists, viewed the process positively and considered them highly motivated and responsive to guidance [1.9, 1.10].

Within the HES, optometrists were often reported as key stakeholders within glaucoma teams [1.11]. For some ophthalmologists, optometrists were critical to the success of services, whilst others highlighted benefits of multidisciplinary teams [1.12, 1.13]. It was also noted personality and motivation was more important than professional background [1.14].

Challenges and barriers

Clinical support was raised as an important factor for optometrists working in HES clinics, with minimal ophthalmology assistance being reflected upon negatively [2.1]. Appropriate banding within secondary care was also raised as problematic by several optometrists and ophthalmologists [2.2, 2.3]. In addition, some ophthalmologists felt frustrated they had less influence in positively steering career progression [2.4]. Staff retention was a challenge in some units, with one ophthalmologist observing the importance of providing career progression [2.5]. Many primary care optometrists felt frustrated they could do more for patients experiencing long waits [2.6, 2.7]. Technology was often reported as a barrier to success, with system links between primary-secondary care still seen as gradually evolving versus being solidly in place [2.8]. Funding for services to run in primary care were raised as a concern, particularly in relation to administration costs associated with the service [2.9].

The question of additional training beyond core competency was raised by optometrists and consultant ophthalmologists, with differing views being presented on the levels required [2.10]. It was noted tensions between different stakeholders, e.g. between primary and secondary care, or between secondary care providers, were detrimental to progress [2.11].

Training, accreditation, and higher qualifications

Optometrists and ophthalmologists spoke positively about experiences of training [3.1, 3.2], with ophthalmologists consistently highlighting they found training optometrists rewarding [3.1, 3.3]. Many ophthalmologists and optometrists supported training beyond core competency to work in glaucoma [3.4]. There were also questions around whether UK optometry courses had adapted, reflecting the ever-increasing role optometrists play in glaucoma [3.5]. Various training models were discussed, including apprentice-style training as well as higher qualifications. The importance of clinical experience was highlighted by many [3.6, 3.7].

Regarding the College of Optometrists’ higher qualifications, similar themes emerged regarding old and new qualifications [3.8, 3.9]. Whilst the issues of cost and placements were raised about new-style qualifications, consensus suggested these were more accessible than older qualifications [3.10]. Optometrists working in glaucoma services for some time described frustrations undertaking qualifications [3.11, 3.12] and these were understood by some in secondary care and relevant to consideration of accreditation of prior experience [3.13]. Indeed, some felt that there was a lack of consistency between expectations for accreditation between medicine and optometry [3.14]. Lack of data around workforce with glaucoma-related qualifications was highlighted as a potential barrier to developing services [3.15].

Level of professional practice

The optometrists we spoke to were working in a variety of roles and managing differing case mixes, with some managing lower risk patients, others managing complex glaucoma. An ophthalmologist who had established a glaucoma filtering service and optometry-led HES glaucoma clinic 20 years ago, noted they always wanted optometrists to manage more complex glaucoma [4.1], whilst others were keen to develop their team to reach this level [4.2]. There were many optometrists and ophthalmologists keen for patients to be seen in primary care [4.3]. However, for some ophthalmologists, it was considered optometrists should take clinical responsibility for seeing patients in primary care [4.4].

Glaucoma laser procedures

We spoke to a mixture of clinical staff and patients about optometrists delivering glaucoma-related laser. Overall, ophthalmologists were enthusiastic about optometrists, or nurses, taking on the role [5.1, 5.2]. When it came to the matter of optometrists delivering laser in primary care, some ophthalmologists were open to the idea [5.3]. An optometrist, delivering glaucoma-related lasers in the HES, considered their training helped with other aspects of glaucoma management [5.4]. The pathway to optometrists delivering lasers was not always straightforward, with consultant support sometimes being seen as inconsistent or unavailable [5.5].

Role of other non-medical eye health professionals

Optometrists and ophthalmologists spoke positively about other eye-health professionals including nurses and orthoptists in delivering care [6.1, 6.2]. Both patients and clinicians highlighted that personality and individual characteristics were more important than profession [6.3]. Several ophthalmologists highlighted optometrists’ existing skillset being advantageous for training [6.4]. However, it was noted by others that there were some tensions between professional groups working in glaucoma in their unit and regarding banding [6.5].

Commissioning, development of local and national pathways

The importance of the role of optometrists in the primary eye-care pathway was highlighted by commissioners [7.1]. Relationships between commissioners, clinicians, and those involved in designing local and national pathways was highlighted by stakeholders as a priority for success [7.2]. For some, the lack of awareness around the role of local commissioners was seen as surprising, with clear communication between all parties being regarded as beneficial [7.3]. Another optometrist highlighted how sometimes having one proactive individual can facilitate progress in establishing services [7.4]. Commissioners felt local stakeholders should have a say in how pathways are designed [7.5], though some highlighted detrimental volatility in ophthalmology community relationships between primary and secondary care, and indeed between consultants in different units [7.6]. Lack of data for glaucoma waiting lists was cited as a frustration for commissioners and others involved in planning [7.7].

COVID 19

Many respondents highlighted changes during the COVID-19 pandemic. For some this took the shape of patients’ best interests coming to the forefront [8.1]. Others considered changes during the pandemic were expediting the shift towards primary care engagement [8.2]. For example, COVID was seen to have encouraged growth in enhanced services in their area by some optometrists, pushing the boundaries of community services [8.3, 8.5]. An exacerbation of existing waiting list problems during COVID was identified as reason for the development of a monitoring service [8.4].

Looking to the future

When asked about the future, many ophthalmologists highlighted optometrists would play an increasingly significant role in delivering both primary and secondary glaucoma care [9.1, 9.2, 9.3].

For some optometrists working in primary care, they were keen to be more involved in glaucoma, with some raising issues around data exchange and remote HES decision making [9.4]. For other optometrists, it was felt good communication with secondary care could facilitate management of more complex cases [9.5]. Some experienced optometrists in secondary care believed they had reached the limits of their progression [9.6, 9.7].

Patient experience

Continuity of care was reported as a priority for many patients, rather than being seen by a particular professional [10.1]. Patients attending clinics were not consistently clear of the professional they were seeing, often assuming they were a doctor [10.2]. Another patient considered it was about the team versus the individual [10.3]. Competence for all clinical staff was raised as key by some patients [10.4, 10.5, 10.6], alongside access to care and waiting times [10.7, 10.8].

Some patients reported strong relationships between themselves and their primary care optometrist [10.9, 10.10]. When considering primary care, patient choice of practice was raised as important by both patients and clinicians [10.11, 10.12]. Patient perception between independent and multiple optometry practices was raised by an optometrist [10.13]. Some patients felt their primary care optometrist may spend more time discussing test findings in comparison to expectations in secondary care [10.14].

Within focus groups, patients with differing complexities of disease discussed their views on who should be treated by whom [10.15, 10.16, 10.17]. Those with advanced glaucoma sometimes described their preference to be under consultant-care [10.18]. However, this particular respondent also felt frustrated they were unable to access primary care optometry for intermittent checks on their pressure [10.19]. Many patients we spoke to seemed happy to be seen by optometrists for aspects of their glaucoma care when they felt this was low risk [10.20, 10.21].

When discussing trained optometrists prescribing glaucoma medications, patients were positive [10.22]. Regarding optometrists delivering glaucoma-related lasers, patients reported training, assessment, and volume of patients were important considerations [10.23, 10.24, 10.25]. The financial aspect of non-medical health professionals (NMPS) delivering care was raised by a few patients [10.26]. Some reported a concern or perception of privatisation of the NHS [10.27]. Communication between secondary and primary care was highlighted as an issue [10.28, 10.29, 10.30].

When questioned about the most important part of their care, patients reported reducing delays, quality and continuity of care were key factors [10.31, 10.32].

Discussion

Optometrists provide significant capacity within glaucoma pathways, involving detection, diagnosis, monitoring and treatment [23, 24]. Despite these contributions, there has been little qualitative research on whether care by optometrists is an accepted alternative to traditional-care, and what factors impact development and sustainability of glaucoma services with optometric involvement. The results of this study show broad support for optometrists delivering glaucoma care, providing insight into multi- stakeholder opinions.

All stakeholders saw potential for expanding glaucoma-related provision in primary care, many reporting this being key to dealing with the capacity crisis. Where primary care services were already running, optometrists felt valued, highlighting the importance of good primary-secondary care communication as vital to maintain and develop services, a factor also emphasised by patients. Patients self-identifying as lower risk were more accepting of care in primary care, as well as those with good relationships with their primary care optometrist. Some patients felt they would receive greater consistency of care in primary care, but those with more complex glaucoma appeared more inclined to being seen in secondary care.

There has been previous work canvassing patient perception of optometrists delivering glaucoma care in the community [25]. However, little qualitative information was presented in this early study. Our study shows appropriate case selection and adequate practitioner training/experience are most important to patients when considering willingness to be seen in primary care. There was suggestion from some about perceived NHS privatisation if care was provided by group-based practices, with many patients preferring to see their usual optometrist. For those establishing primary care services, providing patient choice of practice may enhance patient acceptance. Good communication between primary and secondary care was referenced as an enabler across participants and as a barrier when communication failed. The use of two-way electronic communication has been described to positively benefit glaucoma referral filtering pathways [26, 27] as well as help successfully facilitate glaucoma virtual clinics [28,29,30]. Investment in well-functioning digital technology should therefore be prioritised, a view supported by participants in our study, and a priority for the government [31] and the NHS [32, 33]. The use of artificial intelligence is proposed to have potential to enhance capacity [34, 35] and further qualitative research about patient and clinician perception of its use would be beneficial.

Positive relationships between optometry and ophthalmology were consistently reported as crucial. For example, where ophthalmologists had invested in training and mentoring, optometrists felt more valued, appearing more committed and empowered to participate in advanced roles. Where relationships were less developed or had broken down, this scenario was a barrier to implementing successful primary care-based services. Ensuring all stakeholders have a voice when establishing services is recommended.

Within secondary care, patients experiencing optometric care spoke highly of their experiences. Given the multidisciplinary nature of HES clinics, patients were sometimes unaware of their clinician’s profession. When asked, some patients reported a preference for seeing an ophthalmologist, citing condition complexity, although such patients had often not experienced optometric care. The use of risk stratification such as the Royal College of Ophthalmologists’ and UKEGS’s joint guidance [36] could help select appropriately matched cases to clinicians. However, some patients reported a preference to see an optometrist and felt competence was about the individual not the profession. Considering patients’ preferences vary, and limitations in risk stratification approaches in advanced glaucoma [37, 38], a bespoke approach based on available local expertise and canvassing feedback from patients within individual services may enhance clinical effectiveness and patient acceptance. Further research into experiences and perceptions of patients with advanced glaucoma attending multidisciplinary services, may help guide those planning services for higher risk patients.

Recruiting and retaining optometrists within secondary care was reported as a challenge by ophthalmologists and optometrists. Banding and career progression were cited as key reasons, with some optometrists reporting case complexity had increased without any associated rise in banding. Interprofessional banding has previously been discussed by Greenwood et al., noting apparent differences in banding between professional groups [39], acknowledging differences may relate to the level of clinical practice and autonomy, in keeping with the views of clinicians in this study. The consensus view was that clinical staff should be paid for their level of clinical practice, autonomy, as well as additional responsibilities within a service, regardless of professional grouping. Service providers may need to ensure they can provide appropriately banded opportunities, recognising the increasingly highly specialised role optometrists and other health professionals have within glaucoma. Leadership development such as the Mary Seacole Programme and the advanced clinical practice (ACP) framework [40] may help support staff development and retention. However, difficulties in ACP implementation have been highlighted [41] and other factors raised by ophthalmologists as problematic to staff retention [42] are likely relevant to other NMPs. Further research in these areas would be beneficial.

The recent NICE guidance for glaucoma recommended SLT be offered as first line treatment, with implications for glaucoma services in providing capacity [17], highlighting the role of healthcare professionals meeting this demand, and stating expectations for training and supervision. Whilst the recent scope of practice of hospital optometrists [14] showed an increase in numbers of optometrists delivering SLT, greater capacity will be needed to meet NICE recommendations. Recently, Konstantakopoulou et al., conducted qualitative research exploring acceptability, enablers and barriers of optometrists delivering SLT [43], concluding an optometrist-delivered service could benefit the NHS. Whilst this work offered a useful multi-stakeholder perspective, it was limited to patients and clinicians from one hospital. The results of our study similarly found a positive perspective for optometrists delivering SLT. With regards to optometrists delivering SLT in primary care, we also noted some patients and clinicians expressed reservations. However, others were open to a primary care-based service, with caveats around appropriate training, equipment, and links to secondary care. One non-randomised UK-based study comparing clinical effectiveness of SLT by NMPs to ophthalmologists [44] showed NMPs to be safe and effective. Further studies may be helpful in providing reassurances.

There was some tension relating to higher qualifications. Some respondents felt these enhanced performance and confidence, where others considered these overly onerous, expensive, and lacked flexibility for those with significant experience. Work by Myint et al., [45] highlighted the importance of practice-based training when developing skills in glaucoma assessment. Having a range of routes to accreditation, including accommodation of prior clinical experience, may reduce obstacles, and programmes such as the OPT [12] and funded ACP apprenticeships may support this. The 2022 NICE guidance states those involved in monitoring and treating patients should have a specific qualification in glaucoma [17], and as highlighted in our study, further work evaluating the workforce with glaucoma related qualifications will help support service planners. Regarding accreditation for performing SLT, in keeping with Konstantakopoulou et al., [43], our study emphasises the importance of gonioscopy, laser safety and patient counselling, rather than a specific qualification. Translimbal direct selective laser trabeculoplasty [46], a newer technique currently being evaluated [47], may lead to simplified training, and support an increased workforce for delivering laser.

There has been some qualitative research surrounding other alternative models of glaucoma care, including glaucoma virtual clinics, but none relate specifically to NMPs [48,49,50]. Baker et al., evaluated multi-stakeholder perspectives of the Manchester Glaucoma Enhanced Referral Service (GERS), concluding optometrists can deliver a high-quality service, acceptable to patients, commissioners, ophthalmologists, and other optometrists. Although Baker’s study was about an enhanced referral service, their findings align with ours. The significant role nurses, orthoptists, and other health professionals play in glaucoma services was highlighted by participants in our study and has been described elsewhere [2, 51, 52]. Whilst the focus of our study was on optometrists, given the scale of their numbers working in both primary and secondary care, further explorative work regarding broader NMP groups in delivering glaucoma care would be beneficial.

Our study is the first to secure multi-stakeholder perspectives from all four UK home countries on the role of optometrists delivering glaucoma care. Whilst we received a perspective from patients attending different models of care in England and Wales, most had their care delivered in secondary care, and further insight from those receiving follow up in primary care would be beneficial, as well as seeking a broader perspective of patients in Scotland and Northern Ireland. Despite this limitation, our study affords a broad multi-stakeholder perspective on the role of optometrists in delivering glaucoma care, with collaborative working, trust and keeping patients at the centre of care all being key priorities. Having an improved understanding of how to successfully engage optometrists within glaucoma services should enable service leads, commissioners, and other stakeholders to work towards the shared goal of maximising capacity and quality within glaucoma services.

Summary

What was known before

  • Optometrists contribute significantly to providing capacity in glaucoma care.

  • There is multi-stakeholder support for enhanced referral services delivered by optometrists.

  • There is evidence to support the role of optometrists delivering SLT laser in a large tertiary hospital.

What this study adds

  • There is notable support from patients, ophthalmologists, optometrists, commissioners, and other stakeholders for developing glaucoma services in primary care, with caveats around training, appropriate case selection and clinical responsibility.

  • Success in developing glaucoma services with optometrists and other health professionals is reliant on multi-stakeholder input, investment in technology and training, inter-professional respect and appropriate time and funding to set up and deliver services.

  • A broader understanding of the viewpoint of patients, clinicians and other stakeholders of the role optometrists could play in delivering SLT laser.