Objective: To describe access, utilisation, patients' preferences and quality of primary eye care. Methods: Three studies were carried out (1) Project one: This was a cross sectional study of consultations for eye conditions in seven general practices in Norfolk and Waveney, located in rural, urban and inner city areas. Anonymised data about age, sex, Read codes, and ophthalmic prescriptions were extracted from electronic records using MIQUEST. All patients with an ophthalmic (that is, eye- related) diagnosis or prescription between 1 st May 2008 and 30th April 2009 were identified. The annual period prevalence, consultation and prescription for eye conditions rates in each practice's population were estimated, and directly standardised using the age and sex distribution of the population of East of England. (2) Project two: This was a cross sectional postal questionnaire survey of the patients with eye conditions identified in project one. The questionnaire included questions on: utilisation of eye care during the previous year, patients' preferences for sources of eye care and indicators of quality of care for selected sight-threatening conditions. The relationships between these variables and individuals' socio-demographic characteristics were investigated. (3) Project three: investigated primary care of ophthalmic conditions recorded in the General Practice Research Database (GPRD). It had two components. The first component included all patients who had any ophthalmic Read code recorded during one year. The second component included all patients who had a Read code recorded for the following chronic sight-threatening conditions during five years: glaucoma, diabetic retinopathy, age related macular degeneration (ARMD) and giant cell arteritis. For both components, rates of consultations, prescriptions and referrals were estimated, and their possible associations with patients' demographic characteristics were investigated. Poisson regression analysis was also performed. Results: Project one: Of a total practice population of 60739,4646 (7.7%) patients had either an ophthalmic condition or prescription or both, of which 3089 (5.1 %) people had an eye condition and 3328 (5.5%) had ophthalmic prescriptions. More females than males had an ophthalmic consultation or obtained a prescription except in preschool children who had more ophthalmic consultations than females. Project two: The response rate was 46.3% (568/1228). The main findings were that patients had a clear preference for seeing their GP for treatment of a red eye which appeared to be associated with geographical proximity to the GP's practice. Females tend to seek eye care more than males. There are also results on quality of care which suggests disparity in care received by deprivation levels. Project three: Overall prevalence of consultation was 13.4%, more females than males. Incidence of consultation for four eye condition (Glaucoma, ARMD, diabetic retinopathy and giant cell arteritis. Prevalence was highest for conjunctivitis 3.11 % in component two, the annual incidence rates of glaucoma, ARMD, diabetic retinopathy and giant cell arteritis were respectively, 9.3, 7.0 , 4.8 and 2.0 per 10,000 population. Conclusion This study provides an original overview of the burden of ophthalmic conditions and of utilisation, access, patients' preferences for sources of eye care and quality of primary eye care in the United Kingdom, Norfolk and Waveney in particular. Such evidence is essential for planning future improvements in eye care in the United Kingdom's National Health Service.

Very little research to date has been conducted within the field of domiciliary eye care in the United Kingdom. However, with the ageing population, this sector is likely to expand in the coming years. The programme of research presented in this thesis investigated the visual needs and demands of domiciliary eye care recipients by conducting a questionnaire based survey involving the housebound population; a retrospective review of sight test record cards examined their clinical characteristics compared to conventional practice-based patients, and determined the changes in self-reported visual function following cataract surgery using the VF-14 instrument. All research was conducted in the North West of England. The initial questionnaire survey obtained 412 responses and highlighted that domiciliary eye care recipients engage in similar leisure activities as the general population of comparable age. Watching television followed by reading were the most frequently-performed activities. Use of PC/ internet browsing was very limited amongst care home residents, but was a common leisure activity performed by almost 40% of domiciliary patients residing in their own homes. The majority of respondents considered that provision of perfect vision would have a positive impact on their quality-of-life; however, poor vision was not cited as a cause for their housebound status. Many respondents (11.8 %) reported symptoms of tear film disorders,which could be amenable to treatment by mobile eye care practitioners. The retrospective review of sight test data (including 650 record cards) revealed that there was a greater prevalence of age-related macular degeneration and cataract in domiciliary eye care recipients, particularly amongst care home residents, resulting in a higher rate of visual impairment compared to conventional practice-based patients aged 70 and over. Cataract was the most common reason for referral to the Hospital Eye Service (37.9% of referrals), indicating that many domiciliary patients are living with correctable visual impairments. Changes in self-reported visual function following cataract surgery were assessed using questionnaires (VF-14) administered pre- and post-operatively to domiciliary eye recipients (n= 52) and in-practice patients (n = 26). Despite having a limited range of daily activities due to their housebound status, domiciliary eye care patients demonstrated significant improvements in self-reported visual function after cataract surgery (median VF-14 score change for care-home patients was 23.4 [range 12.5-55.0, P < 0.001]). The results indicate that where it is in the best interests of the patient, domiciliary optometrists should not be reluctant to refer housebound individuals for cataract surgery.

High street optometric practices are for-profit businesses. They mostly provide sight testing and eye examination services and sell optical products, such as spectacles and contact lenses. The sight testing services are often sold at a vastly reduced price and profits are generated primarily through high margin spectacle sales, in a loss leading strategy. Published literature highlights weaknesses in this strategy as it forms a barrier to widening the scope of services provided within optometric practices. This includes specialist non-refraction based services, such as shared care. In addition this business strategy discourages investment in advanced diagnostic equipment and higher professional qualifications. The aim of this thesis was to develop a greater understanding of the traditional loss-leading strategy. The thesis also aimed to assess the plausibility of alternative business models to support the development of specialist non-refraction services within high street optometric practice. This research was based on a single independent optometric practice that specialises in advanced retinal imaging and offers a broad range of shared care services. Specialist non-refraction based services were found to be poor generators of spectacle sales likely due to patient needs and presenting concerns. Alternative business strategies to support these services included charging more realistic professional fees via cost-based pricing and monthly payment plans. These strategies enabled specialist services to be more self-sustainable with less reliance on cross-subsidy from spectacle sales. Furthermore, improving operational efficiency can increase stand-alone profits for specialist services. Practice managers may be reluctant to increase professional fees due to market pressures and confidence. However, this thesis found that patients were accepting of increased professional fees. Practice managers can implement alternative business models to enhance eye care provision in high street optometric practices. These alternative business models also improve revenues and profits generated via clinical services and improve patient loyalty.

The purpose of this study was to determine whether naïve Bayesian artificial intelligence could accurately predict clinical decisions made during the referral refinement of Chronic open angle glaucoma (COAG) by three specialist independent prescribing optometrists using the highly structured standard operating procedure (SOP) adopted by the Community Ophthalmology Team (COT) of the West Kent Clinical Commissioning Group (CCG). The effectiveness of the COT, in terms of reducing false positive referrals and costs to the National Health Service (NHS), was also explored. This was the first study of its kind. Treating the study as a clinical audit allowed collection of unconsented fully anonymised data from the worst affected eyes or right eyes of 1006 cases referred into the COT. Each case was classified according to race, sex, age, family history of COAG, reason for referral, intraocular pressure and its inter-ocular asymmetry (Goldmann Applanation Tonometry), several optic nerve head dimensions (vertical size, cup disc ratio and its inter-ocular asymmetry; dilated stereoscopic slit lamp biomicroscopy with Volk lens), central corneal thickness (ultrasound pachymetry) and the severity of any visual field defects (Humphrey Visual Field Analyser, SITA FAST 24-2 testing strategy, Hodapp-Parrish-Anderson classification). Grouping of data into multiple cut-off points was informed by previous research and National Institute for Health and Care Excellence (NICE) guidelines. Preliminary analyses showed that most cases (79%) were discharged, 7% were followed up and 14% were referred to the NHS hospital eye service. The high discharge rate led to NHS cost savings of over £50 per case. Previous reports of increased intraocular pressure with central corneal thickness and increased cup disc ratios with cup disc size were also confirmed. Despite a high degree of inter-dependency between clinical tests, which violated the key assumption of naïve Bayesian analyses, the scheme learned rapidly and its weighted accuracy, based on randomised stratified tenfold cross-validation, was high (95%, 2.0% SD). However, false discharge (3.4%, 1.6% SD) and referral rates (3.1%, 1.5% SD) were considered unsafe. Making the analysis cost sensitive led to an 80 fold increase in COT follow-ups that would have reduced cost effectivity. The transferability of likelihood ratios was explored along with their use, compared to Chi-square, to rank clinical tests and explore redundancy in the SOP adopted by the COT. In summary, high discharge rates were consistent with the level of false positive referrals for suspected COAG reported in the literature and reduced NHS costs. Although use of a structured SOP led to high accuracy, naïve Bayesian artificial intelligence could not safely predict the decisions of COT optometrists as it caused too many false discharges and referrals. More sophisticated forms of machine learning need to be explored.

In recognition of the increasing prevalence of diabetes in Brunei, and the expected increase in diabetic retinopathy (DR), primary health centre based DR screening was introduced in 2006 for seven health centres in the Brunei-Muara district. The Brunei National Prevention of Blindness from Diabetic Retinopathy is a policy document calling for DR screening to be made systematic at a national level. However, the effectiveness of the model in practice was not evaluated and the DR screening programme was launched without a baseline survey and situation assessment. Consequently, the responsiveness of the health system to embed a systematic approach to DR screening has faced many constraints and was slow to evolve. This study has provided evidence to support the implementation of the policy document and baseline information on the gaps and challenges within the key service provision stages for DR screening and treatment. The overall objective of this thesis was to evaluate the DR screening model in the Brunei-Muara District. Results from this study suggest that the DR screening model in Brunei-Muara is partially systematic. The main findings showed that key processes are in place at different stages of DR screening and treatment and that sufficient resources have been allocated to detect sight threatening diabetic retinopathy (STDR) at primary health centres (PHCs) and to treat STDR at the national eye centre (NEC). This was supported by the good DR annual screening uptake rates (77%) and low DR prevalence rates (5.8%) reported in this study. However, the lack of monitoring of both the implementation processes and screening effectiveness was viewed as key limitations in the programme. This was evident through process gaps observed throughout the DR screening and treatment pathway including the identification of patients for screening at PHCs, GP to DR referral process, referral for treatment processes to NEC and disease registers that were not integrated and lacked accuracy. This was also backed by evidence that DR screening coverage rates were low (56%) across all health centres. Based on a generic framework to analyse development of DR screening programmes used in this study, the existing screening model could be enhanced by improving screening coverage rates, universal access to DR treatment, trained and certified workforce, implementation of a call and recall system and systematic digital photography screening system. However, further studies are required before these recommendations could be implemented.

„Health for all Children‟ (Hall and Elliman, 2006), gives clear recommendations regarding the screening of young children for possible visual difficulties, the focus of which is the detection of amblyopia, defined as,„poor vision due to abnormal visual experience early in life‟ (Webber and Wood, 2005). This policy with its recommendation of the screening of all children between the ages of 4 and 5 was found to be delivered in many ways by different Health Authorities up and down the UK. This raises various questions, including: „What are the determinants that drive the approach taken in terms of implementing this policy?‟ There is a large body of literature suggesting a link between deprivation/poverty and increased health issues; (Aber et al., 1997; Bramley and Watkins, 2008; Howard et al., 2001; Scott and Ward, 2005). There is also evidence that there is a link to amblyopia specifically, (Williams et al., 2008). This research has looked at links between three variables relating to vision screening for amblyopia in four and five year olds; service costs/funding, practice issues and population characteristics. With regard to the last it looked specifically at levels of deprivation as measured by Indices of Multiple Deprivation, or IMD scores(Noble et al., 2008). IMDscores are a useful way of capturing levels of deprivation in a particular area in that as well as providing an overall „score‟ for deprivation, it is possible to see how this score has been made up from various indicators relating to different aspects of an area. The rationale behind this approach is that where several aspects of an area can be described as involving deprivation, these aspects combine and exacerbate each other producing an effect that is greater than the sum of its parts. This „exacerbation‟ is taken into account in the formula for calculating the overall score. In order to obtain information about cost and practice issues, a questionnaire was issued as a Freedom of Information (FOI) request to each of the 152 Primary Care Trusts (PCTs) which made up the map of service delivery in England at the time of the request. Use of an orthoptist (the key medical practitioner regarding eye muscle control/movement and amblyopia) was found to be the most significant factor in terms of practice and also costs for the screening. In particular, use of an orthoptist resulted in a greater and more up to date range of tests being used as well as in a higher cost for the service. Following this collection of quantitative data, a number of follow up questions were pursued by telephone/email/interview. These „case studies‟ were a sub-sample of orthoptists selected on the basis of peculiarities suggested by their returns from PCTs or because they are „key players‟ regarding the work of orthoptists. One determinant regarding the approach to practice/cost is that eye-care services may be taking account of the socio-economic make-up of an area when deciding how/whether to deliver the screening to the 4 and 5 year olds within it. Using all data and therefore including PCTs that don‟t screen, there was a significant relationship between deprivation and use of orthoptists (p<0.05). Orthoptists are more likely to deliver the screening in areas of deprivation. Practice issues were found to follow from the use of orthoptists as opposed to school nurses/school nurse assistants to deliver the screen. Furthermore, there was an increased cost in using orthoptists to deliver the screen. The „mechanism‟ that results in the use of orthoptists to deliver screening in areas of deprivation, is a combination of this group of professionals engaging actively and using their discretion to commission an orthoptist screen, but alsothe use of a notion of „local justice‟ as exhibited at a textural level in the guidelines on clinical commissioning (as well as in the Hall report itself). Whilst policy exists requiring a thorough visual screen for all children including those in areas of deprivation, it is essentially the conscienceof orthoptists (facilitated by their professional discretion) that ensures that children in areas of deprivation are more likely to receive the screenfrom this key medical practitioner in the area of children‟s eye care.