Deprivation and the location of primary care optometry services in England

Primary care optometrists offer NHS sight tests under the General Ophthalmic Service (GOS), or private eye examinations, and increasingly in the past two decades also provide wider NHS services, typically as part of local commissioning in England, or, for example, within an enhanced GOS in Scotland. Plans for transformation in ophthalmology make recommendations for greater use of primary care, provided from either independent practices or chains of multiple optometric practices. The College of Optometrists and The Royal College of Ophthalmologists joint statement “our vision for safe and sustainable patient eye care services” recommends that integrated pathways should include optometrists as first contact practitioners for: urgent eye care; referral triage/advice and guidance; primary care-based management for new, low risk patients; and primary care-based management for follow up of patients with long term low risk conditions [1]. The statement notes the vision for the future is pathways that ensure patients are prioritised based on clinical need and that they receive care that is appropriate and accessible. Accessibility to services is, therefore, important for GOS sight testing, but also wider eyecare services, i.e., accessibility to the pathways currently provided or to those potentially feasible within primary care in the future. However, there is limited published information on the association between location of primary care optometry practices and deprivation in England. Socio-economic deprivation in the UK has been associated with presentation with more advanced eye disease [2–4] and lower uptake of services [5]. A previously published small-area analysis of GOS activity in Leeds found populations in the least deprived quintile were more likely to have NHS funded eye examinations than those in deprived areas [5]. Research elsewhere observed demonstrable inequalities in small-area data modelling in Essex [6], reinforcing the need to address inequalities. While there is some evidence that the distribution of optometry practices in Scotland, where the GOS is enhanced, may be more balanced [7, 8], and thus potential differences in eye examination uptake across social strata may not solely be related to their availability, accessibility to services remains a central tenet for NHS provision.

In this analysis we have used data from NHS Digital [9] on the location of primary care optometric practices offering NHS sight-testing and associated eyecare services in England. These data, first published in August 2016, are updated quarterly, with this analysis being based on data up to January 2023. There are ~7107 optometric practices in England, a mean rate of approximately 12.5 per 100,000 of the population. Data reflecting various Integrated Care Boards (ICB) in England show substantial variations in the rates of optometric practices, for example, ranging from 16.1 practices per 100,000 population in Birmingham and Solihull to 7.7 practices per 100,000 population in Cambridgeshire and Peterborough. It should be noted that these figures reflect optometric practices (i.e., the premises or facilities for eyecare provision) versus data representative of the number of optometrists present, consulting rooms and appointment provision; there may be significant variation in the size of practices and the number of consulting rooms (and therefore appointment capacity). Further, domiciliary provision is not reflected. Examining these data, we have determined the rate of optometric practices per 100,000 population set against deprivation, using deciles for the Index of Multiple Deprivation (IMD) [10]. These data are shown for England in Fig. 1. Table 1 shows the 95% confidence intervals (CIs) for these rates per IMD decile, calculated using the Office for Health Improvements and Disparities recommended Byar’s method for proportions and crude rates. These data are striking, with a stark contrast being evident in the rate of optometric practices per 100,000 population across the deciles of deprivation. NHS Digital data also allows us some examination of closure of primary care optometric practices. In the last two and a half years in England there have been 467 closures, with 264 openings in the same period. Within England there is a general increase in the percentage of optometric practice closures as the level of deprivation increases, also illustrated by the data in Table 1. The 95% CI for practice closure rates per IMD decile are shown in the table, again calculated using Byar’s method. The CIs are narrow, with the exceptions of D2 and D9; it can be seen that the percentage of practice closures is significantly greater than the England average in the most deprived decile while the opposite is true in the most affluent decile.

Fig. 1. Optometric practice rates per Index of Multiple Deprivation decile.

Rate of optometric practices per 100,000 population versus Index of Multiple Deprivation (IMD 2019) deciles from the least deprived (D1 - LD) to the most deprived (D10 - MD), showing a significantly reducing rate of practices from the least to the most deprived areas (orange horizontal line reflects the mean rate of practices per 100,000 population in England).

Table 1.

Rate of optometric practices per 100,000 of the population per Index of Multiple Deprivation (IMD 2019) decile and companion lower and upper 95% confidence intervals, with D1 being the least and D10 being the most deprived areas.

IMD decile	Optometric practices open (N)	Population served (N)	Optometric practices per 100K population (95% CI)	Optometric practice closures (N)	% Optometric practice closure rate (95% CI)
D1	1027	5,603,911	18.33 (18.31–18.35)	61	5.94 (5.90–6.01)
D2	893	5,697,232	15.67 (15.66–15.69)	59	6.61 (6.56–6.69)
D3	891	5,832,954	15.28 (15.26–15.29)	43	4.83 (4.78–4.91)
D4	819	5,796,889	14.13 (14.12–14.15)	50	6.11 (6.05–6.20)
D5	703	5,720,152	12.29 (12.28–12.31)	39	5.55 (5.49–5.65)
D6	695	5,764,872	12.06 (12.04–12.07)	49	7.05 (6.99–7.16)
D7	601	5,591,424	10.75 (10.74–10.77)	41	6.82 (6.75–6.95)
D8	545	5,586,550	9.76 (9.74–9.77)	47	8.62 (8.55–8.76)
D9	556	5,512,645	10.09 (10.07–10.10)	37	6.65 (6.58–6.79)
D10	377	5,443,509	6.93 (6.92–6.94)	41	10.88 (10.77–11.07)
England total	7107	56,550,138	12.57 (12.57–12.57)	467	6.57 (6.56–6.58)

The table also indicates the number and percentage of practice closures in each decile (and lower and upper confidence intervals) during the past 2.5 years.

Our analyses reveal substantial variations in the crude rate of optometric practices per 100,000 of population, with this rate being much lower in more deprived versus more affluent areas, with some evidence for increased practice closures in the most deprived areas. These data deserve flagging within the narrative of existing research on deprivation and eyecare, but moreover in relation to plans to transform ophthalmology, with more services being proposed for delivery within primary care. Arguably of necessity, likely driven by the economics of the NHS’s funding models for primary care optometry, i.e., a requirement for businesses to use cross-subsidisation from spectacles sales versus income derived from eyecare provision (for GOS sight test/community ophthalmology schemes), optometric practices are more prevalent in the more affluent areas. While uptake of services is multifactorial and beyond the matter of accessibility alone, including for example previously raised concerns about lack of awareness and perceptions of costs [11], there is a pressing need for services to be located more evenly, minimising variations in accessibility as the kernel for uptake of services. While it might be argued that regardless of these findings, for many patients, optometric practices may still be more accessible than traditional secondary care ophthalmology services, local Health and Wellbeing Boards and those responsible for commissioning must create NHS contracts in England permitting optometry practices to be economically viable within the most deprived areas or alternatively develop outreach services in such areas [11]. Legge et al’s analysis in Scotland [7] provides some evidence to suggest that the funding model in Scotland has enabled optometry practices to function in all socio-economic areas. Our analysis of NHS data here appears to show this scenario is far from so in England.

Author contributions

RAH, JH and CHF conceived and designed the study, supported by JR and MB. JH performed the analyses, supported by RAH and CHF; RAH wrote the manuscript; JH, CHF, JR and MB provided critical review of the manuscript.

Competing interests

The authors declare no competing interests.