Greater Manchester community glaucoma monitoring pathway

The challenge

Manchester Royal Eye Hospital’s glaucoma service was under sustained pressure from increasing demand for glaucoma follow-up, particularly after the secession of alternative providers in the area. Clinics were operating at or beyond capacity, leading to long waiting times and delayed monitoring. This presented a clear clinical risk, as delays in glaucoma follow-up can lead to avoidable and irreversible sight loss.

The approach

The system recognised that a large proportion of glaucoma follow-up is protocol-driven and could be safely delivered outside hospital settings, provided clinicians were appropriately trained and supported. A community-based glaucoma pathway was piloted, enabling stable patients to be monitored by accredited primary care optometrists, with consultants retaining oversight.

How it was delivered

• Accredited workforce: Optometrists had completed formal training and accreditation (College of Optometrists’ Professional Certificate in Glaucoma, or equivalent), supported by supervised practice.
• Standardised pathways: Clear protocols and clinical thresholds for re-referral were agreed.
• Senior clinician oversight and support: Virtual review of clinical information was used to provide advice and guidance for primary care optometrists enabling specialist input without patients requiring hospital attendance. All patients were reviewed virtually after three years as part of a clinical evaluation to assess safety and impact of the service.
• Digital enablement: Diagnostic imaging was shared to support remote decision-making if required.
• Governance framework: Audit and clinical evaluation, feedback and shared learning ensured safety and consistency.

Impact 

• Most patients were retained in the service for the course of the pilot, with just 6 per cent requiring review back in the hospital eye services.
• There was 94 per cent agreement between consultant ophthalmologists and primary care optometrists on decision-making, with the remaining cases showing a more cautious approach by optometrists versus consultant ophthalmologists in re-referring patients to the hospital eye service.
• A patient satisfaction survey showed 100 per cent respondents had overall satisfaction with the service, with very high levels of confidence in the primary care optometrist.
• Optometrists felt the management plans were appropriate to support monitoring and decision making, with the vast majority keen to continue to deliver the service.
• Carbon emissions were estimated to be reduced by approximately two-thirds in the community monitoring service, versus travel to the hospital.

Key learning

• Clinical safety depends on standardisation, supervision and governance.
• Virtual consultant oversight enables scale without increasing risk.
• Trust between sectors is a critical enabler of pathway adoption.
• Starting with clearly defined patient groups allows safe and sustainable expansion.