Getting It Right First Time (GIRFT), part of NHS England, has set out a clinical framework for delivering consistent, patient-centred glaucoma care across England.
Glaucoma is the second leading cause of blindness in the UK, and case numbers are projected to reach 1.6 million by 2060, a 60% increase. Because sight loss from glaucoma is irreversible once it occurs, delays in detection or follow-up can have permanent consequences for patients’ independence and quality of life.
The document was developed with extensive input from the Royal College of Ophthalmologists, the College of Optometrists, Royal National Institute of Blind People (RNIB), Glaucoma UK, the UK Ophthalmology Alliance and other stakeholders. It responds in part to an October 2025 RCOphth position statement calling for a shift of ophthalmology-led care from hospitals into community settings, and it is intended to inform NHS Online, a new virtual appointment service launching in 2027 that will initially prioritise nine conditions, including glaucoma.
Detection and referral filtering in primary care
The pathway begins with increasing sight test uptake among high-risk and deprived populations, since deprivation is linked to more advanced disease at diagnosis. Because NHS sight testing is a single, unfunded episode with no built-in mechanism for rechecking uncertain results, up to 50% of glaucoma referrals from optometrists can be false positives. To address this, the guidance recommends two referral-filtering services, delivered by optometrists without requiring glaucoma consultant oversight:
- Glaucoma repeat measures service (GRMS): the original optometrist repeats key tests (intraocular pressure and visual fields) on a different day to confirm suspected ocular hypertension or unreliable field results before referring.
- Glaucoma enhanced case-finding service (GECFS): delivered by optometrists with additional accreditation (such as the College of Optometrists’ Professional Certificate in Glaucoma), involving fuller assessment including optical coherence tomography (OCT) imaging, for patients showing signs such as suspicious optic discs.
Evidence cited includes the Manchester Glaucoma Enhanced Referral Scheme, where introducing this filtering reduced the proportion of new referrals discharged at first hospital attendance from over 50% to 15%. Patients should pass through only one of these two services, not both, and urgent presentations (advanced glaucoma, acute angle closure or very high eye pressure) bypass filtering entirely.
“Delivering the glaucoma pathway well depends on clinicians and organisations working together across professional and organisational boundaries, with mutual trust and a shared commitment to improvement”
– Professor Tim Briggs, GIRFT Programme Lead, from GIRFT Best Practice for Glaucoma Service.
Referral to a single point of access
Optometrists should refer into secondary care via a single point of access (SPOA) rather than directly to named providers. This standardises referral forms and a minimum clinical data set, supports timely, risk-based triage, enables genuinely informed patient choice and allows bidirectional data flow between community and hospital services. New clinical events in existing glaucoma patients (such as a newly identified cataract) should also route through the SPOA. Urgent and emergency referrals bypass the SPOA and go directly to eye departments.
Diagnostics and virtual review
A central recommendation is the diagnostics asynchronous virtual review assessment pathway (DAVRAP): patients attend in person for diagnostic tests (imaging, visual fields, eye pressure measurement) but leave before a clinician reviews the results remotely at a later date, deciding whether a face-to-face consultation is needed. This separates the technician-led data-acquisition role from the higher-level clinical review role, mirroring the model used in diabetic eye screening, and allows far more patients to be reviewed per session than under traditional face-to-face clinics. A Devon case study found patient throughput per half-day session rose from 15 to 70 after adopting this model.
GIRFT recommends that when secondary care delivers follow-up, at least 50% of appointments should use DAVRAP, with risk stratified using tools such as GLAUC-STRAT Fast. A defined minimum data set (history, visual acuity, anterior and posterior OCT, intraocular pressure, corneal thickness, perimetry) must be collected to support this. Every DAVRAP patient must be told who their named consultant is, even though day-to-day reviews may be carried out by other qualified team members.
Continuity of care
Because glaucoma is a lifelong, progressive condition managed through longitudinal data, continuity of care is treated as essential, particularly at transition points between providers. The guidance draws on General Medical Council (GMC) good medical practice duties around sharing information promptly and delegating safely, and recommends that each patient have a named provider responsible for diagnosis, treatment, failsafe processes and long-term follow-up, supported by a locally based glaucoma consultant. Case studies from London and Devon illustrate community-based asynchronous review clinics fully integrated into hospital governance structures.
Safe and effective interventions
Surgical, laser and minimally invasive glaucoma surgery decisions should be made by, or in consultation with, a glaucoma consultant who has access to the patient’s full longitudinal data set. Cataract surgery in glaucoma patients can be performed by any competent cataract surgeon, but only after a glaucoma subspecialist has reviewed the case. Only interventions and devices supported by robust evidence (or delivered within a clinical trial) should be used.
“Now is the time for all clinicians and organisations involved in glaucoma care to come together and work collaboratively, using this document to inform service improvement and support the delivery of high-quality, patient-centred care”
– Louisa Wickham, NHS England National Clinical Director for Eyecare, from GIRFT Best Practice for Glaucoma Service.
Follow-up intervals and discharge
Follow-up frequency should reflect clinical risk rather than blanket protocols. Evidence cited shows fewer than one in five people with ocular hypertension convert to glaucoma within five years, supporting GIRFT’s recommendation that most such patients need visual field testing no more than once a year. The guidance provides a detailed table of recommended review intervals (broadly 6–24 months) depending on diagnosis, conversion/progression status and intraocular pressure control, with consultant review triggered for uncertain or confirmed progression.
Discharge should follow National Institute for Clinical Excellence (NICE)-based criteria: patients without glaucoma, or ocular hypertension/glaucoma suspect patients who show no conversion after roughly three years or three data sets, should be discharged back to routine community optometry, with a discharge letter sent to the patient, GP and optometrist. A provider with a 0% annual discharge rate is flagged as an outlier requiring audit; an 80% five-year discharge benchmark is suggested for ocular hypertension patients.
Urgent and emergency care
Providers must guarantee 24/7 access to urgent and emergency eyecare, particularly given the risk of sight-threatening complications such as bleb-related endophthalmitis after glaucoma surgery. The document reprints relevant GMC guidance on continuity of care, delegation, competence and consent, and includes two real-incident-based case examples where poor handover arrangements led to dangerous delays and patient harm. Providers unable to offer their own 24/7 emergency service must have formal service-level agreements with another provider; a telephone advice line alone is not considered sufficient emergency provision.
Service models: synchronous vs asynchronous community care
The guidance compares asynchronous pathways (as used in DAVRAP) against synchronous community models, where optometrists with higher glaucoma qualifications see and review patients in the same appointment. Examples include Manchester’s primary eyecare glaucoma service pilot, plus established models in Scotland, Wales and Northern Ireland. Asynchronous models offer higher throughput per clinical session, while synchronous community models benefit from the scale of the wider optometry workforce and may improve patient experience through direct discussion of their condition. GIRFT concludes that a mixed economy of both approaches is a reasonable way forward as services transform.
“Getting It Right First Time is especially important in glaucoma, where delays, fragmented pathways and unwarranted variation can lead to irreversible sight loss. GIRFT provides a shared framework for delivering timely, consistent and patient-centred care while making the best use of our entire multidisciplinary workforce.”
– Andrew Tatham, Consultant Ophthalmologist, NHS Lothian; President UK and Eire Glaucoma Society (2024–25).
Quality, training and research
Providers are expected to apply failsafe systems, including clinical risk stratification and monitoring against a ‘Latest Clinically Appropriate Date’, with clear patient instructions on what to do if this date is missed. The document also calls for contributions to workforce training across medical, optometric and nursing professions, and participation in clinical research and registry data collection, including from primary care optometry and third-sector organisations.
Conclusion
The guidance closes with a set of measurable benchmarks GIRFT will use to assess best practice adoption, alongside detailed appendices covering minimum data sets, follow-up intervals, discharge criteria and relevant GMC extracts, intended to support providers and commissioners in auditing and improving their local glaucoma pathways.
Read the new GIRFT Best Practice for Glaucoma Services here.
