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Alexander Chiu and his co-authors highlight innovations influencing healthcare advancement and how trainees can get involved.


Hospital eye services (HES) were under great pressure to meet demand, even before the COVID-19 pandemic. This pressure has increased with the cancellation and postponement of elective services due to social distancing requirements.

Efforts to meet this demand have led to amazing innovation in how care is delivered, including the increased use of remote and virtual clinics. This article looks at the NHSX initiative to further improve the delivery of eyecare using electronic referrals and image sharing.

How do patients access ophthalmology services?

The majority of referrals to HES are generated in primary care optometry. Many, however, have to go via the patient’s GP as there is often no direct referral route other than fax or email. This is helpful as they can attach the medical history with the referral and are made aware of what is happening with their patient, but it also causes duplication and delay.

During the pandemic, NHS England and NHS Improvement, together with key eyecare stakeholders, developed the COVID-19 Urgent Eyecare Service (CUES), allowing many conditions to be managed in the community with only high-risk patients being referred to the HES [1]. Commissioned locally by clinical commissioning groups (CCGs), this pathway is delivered by primary care optometrists acting as urgent eyecare hubs and supported by hospital ophthalmology services. The success of this scheme has highlighted the potential for greater integration between primary and secondary care and demonstrates how technology can be used to manage more patients in the community.

The case for electronic eyecare referrals

There are many examples in literature demonstrating the impact of electronic referrals on HES capacity, particularly when combined with image sharing. For example, studies have shown that safe, quicker and better-informed triage and provision of remote or community care reduces the numbers of patients seen in hospital [2,3]. Electronic referral systems have also already been introduced in Scotland, Wales and pockets of England to good effect [4], although local commissioning change is often needed to realise the full benefits.

“Digital transformation is shaping our NHS in many positive ways and assisting patients during the pandemic”

Due to this, the ability to send referrals electronically and increase image sharing has been identified by stakeholders across eyecare as a key enabler to transform how eyecare is delivered. This is reflected in the eyecare restoration roadmap which was developed in collaboration between the Royal College of Ophthalmologists, the College of Optometrists, the Local Optical Committee Support Unit (LOCSU), the Royal National Institute of Blind People (RNIB), the Getting It Right First Time (GIRFT) programme, the Clinical Council for Eye Health Commissioning and NHS England and NHS Improvement. In particular, the roadmap sets out integrated pathways across primary and secondary care which rely on electronic sharing of clinical data and images.

Referral feedback

Referral feedback allows optometrists to support patients’ ongoing care and can help avoid unnecessary referrals in the future. In March 2015, the Royal College of Ophthalmologists and College of Optometrists issued a joint statement supporting sharing of the outcome of the referral between ophthalmologists and optometrists, with patient consent [5]. Many optometrists, however, report that they do not receive feedback on their referrals [6]. Electronic eyecare referral systems therefore offer an opportunity to improve referral feedback by offering an option for the outcome of the referral to be sent electronically to the referring optometrist.

Patient summary care records

One of the recognised advantages of sending optometry referrals via the patient’s GP is the ability to see the patient’s medical history which often accompanies GP referrals. To date, establishing access to the patient’s medical history has proved difficult for optometrists. Electronic eyecare referral systems provide an opportunity to develop a way of obtaining the patient’s relevant medical information, either by integrating with GP systems or linking with the summary care record, thus reducing the workload for GP practices.

Better quality triage

Electronic eyecare referral systems will require a referring optometrist to enter minimum referral data for each pathway and will also permit relevant images to be attached. Provided with this structured information and images, ophthalmologists are able to offer better-quality triage, and in many cases may be able to provide a remote consultation or re-direct the patient to community services.

The future

NHSX held a user requirements workshop with clinical stakeholders which set out the minimum viable product for such a system. This led to the creation of a purchasing framework and allocation of funds which allowed NHS regions or Integrated Care Systems (ICS) to purchase electronic eyecare referral systems through the framework.

Many regions have taken advantage of this offer and proceeded with the procurement of an electronic eyecare system which was best suited to their requirements. As a result, regions are working with local systems to implement electronic eyecare referral systems. Regional teams are bringing people working within eyecare together to determine how these systems would best fit into their patient pathways to benefit patients.


Digital transformation is shaping our NHS in many positive ways and assisting patients during the pandemic. Electronic eyecare referral systems have the potential for huge benefits for patients, the HES, optometrists and GPs. There are, however, significant implementation challenges given the scale, complexity and variations in referral pathways.

If you are passionate about improving healthcare through digital transformation you might see this as an opportunity to get involved. If there are plans to implement an electronic eyecare referral system in your Trust you might consider contacting your department to see if they are looking for digital champions. Likewise, if you feel that your service would benefit from greater connectivity with primary care and increased sharing of clinical images, please do contact your NHSE/I region to see if one of these will be available where you work.

Lastly, the NHSX eyecare digital playbook has published many real-world examples of technological advances used to improve communications between primary and secondary eyecare as well as other examples of improvements in service provision. Please visit their webpage to find out more



1. The College of Optometrists. COVID-19 Urgent Eyecare Service (CUES) in England:

2. Kern C, Fu DJ, Kortuem K, et al. Implementation of a cloud-based referral platform in ophthalmology: making telemedicine services a reality in eye care. Brit J Ophthalmol 2020;104(3):312-7.
3. Cameron JR, Ahmed S, Curry P, et al. Impact of direct electronic optometric referral with ocular imaging to a hospital eye service. Eye (Lond) 2009;23(5):1134-40.
4. Annoh R, Patel S, Beck D, et al. Digital ophthalmology in Scotland: benefits to patient care and education. Clin Ophthalmol 2019;13:277-86.
5. The Royal College of Ophthalmologists. Sharing patient information between healthcare professionals – a joint statement from The Royal College of Ophthalmologists and College of Optometrists:

6. Powell S. Ophthalmologist says providing referral feedback is a “no-brainer”. Optometry Today 12 June 2018.

(All links last accessed April 2021)


  1. Electronic eyecare referral systems have the potential to improve quality of referrals, referral feedback and access to patient summary records to improve patient care and system efficiency. 
  2. Digital transformation is shaping our NHS, however, there are significant implementation challenges given the scale, complexity and variations in referral pathways.
  3. NHSX eyecare digital playbook has published many real-world examples of technological advances used to improve communications between primary and secondary eye care as well as other examples of improvements in service provision:




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Alexander Chiu

Clinical Lead NHSEI Ophthalmology Workforce.

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Neylya Solomons

Innovation team, NHSX.

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Guy Mole

NHS England and NHS Improvement.

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