Delivering hospital eye care closer to home: what needs to change nationally to enable scale

The shift to delivering care closer to home is not hypothetical, it is already happening, driven by committed clinicians, commissioners and system leaders who are working together to redesign care around patient needs.

However, it is also clear that this progress is harder than it needs to be.

National action is required to move from pockets of innovation to consistent, scalable delivery. This is not about replacing local initiative but about creating the conditions in which that initiative can succeed more easily, more quickly and more reliably.

Informed by insights from our programme of work to support delivering hospital eye care closer to home, which generated guidance for delivering the ambition locally,  there are six enablers that would support change at a national level to enable consistent, safe and scalable delivery of eye care closer to home. 

1. Improving data visibility
2. Digital interoperability.
3. Aligning financial and commissioning models.
4. Standardising workforce frameworks.
5. Strengthening national messaging.
6. Ensuring policy coherence.

While all systems recognise the importance of understanding demand, outcomes and pathway flow, many struggle with fragmented or incomplete data. The absence of standardised coding for subspecialties, inconsistent datasets across organisations and limited visibility of community activity all contribute to a lack of clarity. This creates difficulty tracking pathways end to end.

National action is required to establish a shared foundation for understanding eye care pathways. This includes defining minimum datasets, standardising coding and ensuring that data from community providers is included within system-wide and national reporting. Without national standards, insight remains fragmented and outcomes are hard to evidence. Local solutions cannot standardise coding, align datasets or create comparability across systems.

National recommendations for regulators and policy leaders

• Define a minimum eye care dataset including pathway activity, outcomes and flow.
• Standardise coding for subspecialties and pathways.
• Enable integration of primary and community eye care data into national datasets.
• Develop national benchmarking tools allowing systems to compare outcomes and pathway performance across systems.

Across every system, the issue of digital fragmentation surfaced not just as a frustration but as a fundamental limitation on how far care could shift safely into the community. Local pathways depend on the ability to share clinical information across organisational boundaries particularly diagnostic images such as optical coherence tomography scans and visual field results, alongside referral information and clinical histories.

These systems remain disconnected, with community providers often unable to access hospital records and hospital clinicians unable to reliably view images generated outside their organisation.

National recommendations for regulators and policy leaders  

• Define a minimum national interoperability standard for eye care pathways.
• Design or procure a consistent digital system that supports patient categorisation by risk, status and urgency, enables pathway tracking, and allows diagnostic images to be shared securely.
• Set national expectations for shared clinical data access across providers.
• Create national interoperability frameworks for digital suppliers.

The current financial and contracting arrangements often limit what is practically achievable. Local systems repeatedly described a misalignment between how care is funded and how they are trying to redesign pathways. Activity is being shifted out of hospital settings but the associated funding does not move with the patient. Acute providers face reductions in income without corresponding reductions in fixed cost, while community services are expected to absorb additional activity without consistent or sustainable funding arrangements.

This context also highlights a wider opportunity for integrated care boards (ICBs) in their emerging strategic commissioning role. As systems increasingly take a whole-pathway view of care, there is potential to move beyond traditional contracting approaches and explore models that better reflect patient journeys rather than organisational boundaries.  

There is a detachment between financial flows and the journey of the patient, which leaves organisations unable to help facilitate the movement of patients without being penalised financially.

National recommendations for regulators and policy leaders

• Reform payment by results (PbR) mechanisms to enable funding to follow the patient across settings, including clearer rules for transferring activity-related income from acute to community providers when care shifts.
• Flexibility in tariff structures and reallocation of money to support community-based delivery.
• Guidance on pathway-level commissioning rather than activity-based models.
• Align financial incentives to support the phased shift of eye care activity from hospital to community settings without destabilising acute providers.

One of the strongest opportunities identified is the untapped potential of the existing workforce, particularly within the community setting. Systems consistently described highly skilled clinicians whose capabilities were not fully utilised due to lack of standardisation, inconsistent accreditation and limited recognition within commissioning frameworks.

This creates variation not only between areas but within systems themselves. Hospital clinicians may be uncertain about the level of expertise they can rely on in community settings, leading to cautious decision-making and unnecessary escalation. Community clinicians may face barriers to accessing pathways because their training or qualifications are not recognised consistently.

National recommendations for regulators and policy leaders  

• Establish a nationally recognised accreditation framework for extended roles linked to pathways and invest in development of these roles and associated skills training.
• Set national expectations to align commissioning with workforce capability, including funding models that reward trained and accredited providers.
• Standardise expectations for supervision and governance ensuring safe delivery across setting.
  
• Align national workforce planning with service transformation, using the forthcoming ten-year workforce plan to support demand modelling, expand extended roles in eye care, and ensure workforce supply matches the shift towards community-based delivery.

While much of the focus in transformation is on service design, patient behaviour plays a critical role in whether new pathways are used effectively. In many areas, community services have been developed but patients continue to default to hospital-based care because it is familiar and perceived as more appropriate. Awareness of alternative pathways remains low and what is often described as ‘patient choice’ is shaped by limited information and system defaults.

National recommendations for regulators and policy leaders  

• Develop a national communications strategy for community eye care explaining when and why patients can be seen outside hospital.
• Integrate messaging into NHS 111 and national triage systems, supporting consistent routing of patients.
• Align with screening programmes and primary care messaging ensuring patients are informed at key entry points.

Policy alignment is challenging and there is noted friction and contradiction, including the balance between patient choice and pathway management, the role of the independent sector alongside community provision and the expectations placed on systems to deliver efficiency while investing in transformation. These tensions do not prevent progress entirely but they introduce friction. They make decision-making more complex, slow down implementation and contribute to variation between systems.

National clarity does not require removing flexibility but it does require providing a coherent direction of travel. Clear articulation of how community eye care pathways fit within wider NHS priorities would support systems to move forward with confidence, rather than navigating competing interpretations.

National recommendations for regulators and policy leaders  

• Ensure alignment of incentives across the system to avoid unintentionally reinforcing hospital-based care over community delivery
• Establish a clear national mechanism for policy triangulation, aligning priorities, funding, performance metrics and guidance into a coherent and consistent set of expectations for systems
• Ensure continued national clinical leadership and specialty input (eg. national clinical directors and clinical reference groups) as responsibilities transition from NHS England to DHSC, to maintain clinically informed service specifications and pathway design.
• Clarify expectations for commissioners on what ‘good’ looks like in pathway redesign, while enabling ICBs to use their strategic commissioning role to design locally appropriate pathways and incentives.