Purchasing good quality eye care: the provider's view.

Vision is arguably our most important sense. Loss of vision can isolate a person and fear of blindness is common in people presenting to ophthalmic casualty departments, no matter how trivial their complaint. In 1994 there were 181 958 registered blind, and 133 823 registered partially sighted in the United Kingdom. The Royal National Institute for the Blind estimates that underregistration affects two in three eligible adults and that nearer a million people are severely visually impaired in the United Kingdom today.' The social, personal, and financial cost of this is high: there is every reason for our society to invest in healthy eye care. The main provider of eye care in the United Kingdom is the Hospital Eye Service and it has three principal tasks. Firstly, it provides a diagnostic and treatment facility which restores vision for conditions where sight loss is reversible, for example, cataract. Secondly, it monitors and treats progressive eye disease to prevent further loss of vision for example, glaucoma and diabetic retinopathy. Finally, it offers information and help to those whose visual loss is irreversible, for example, in age related macular degeneration. The hospital eye service is based in hospitals because the equipment and facilities needed for diagnosis, investigation, and treatment are complex and expensive. A basic outpatient kit consists of a slit lamp microscope to give a magnified cross sectional view of the eye, direct and indirect ophthalmoscopes to examine the retina, a tonometer to measure introcular pressure, equipment to test the size and sensitivity of the visual field, and lenses to measure refraction. More detailed examination requires special photographic techniques some of which use fluorescent dyes, keratometry, ultrasound, and electrodiagnostic tests as well as radiological imaging of globe, orbit, and brain. Specialist nurses, ophthalmic photographers, field technicians, orthoptists, and optometrists are commonly employed in eye departments to supplement and support ophthalmologists. Treatment in clinic includes topical and systemic drugs, laser surgery, and minor eyelid operations. More complicated procedures require sterile operating theatre facilities with operating microscope, microsurgical instruments, and specialist equipment for small incision surgery and posterior eye disease. A good eye service strives to provide an effective interface between complex technology and accessible, patient focused care and this is what a purchaser should seek to buy. In this article I shall outline aspects of the organisation of such a service: in outpatient management, use of clinical guidelines, staff training and development, and education of patient and primary care professionals, performance monitoring, and service developments. I will also indicate what to look for in key ophthalmic conditions, cataract, glaucoma, diabetic retinopathy, macular degeneration, and eye problems in children. Table 1 summarises the list.