Visit COVID-19 resources

[Skip to Content]

Atlas of variation in risk factors and healthcare for vision in England

18 August 2021

This new ‘Vision Atlas’ represents the first Public Health England (PHE) output solely focused on eye health. Ophthalmology is the largest outpatient specialty in England. The atlas shows there were 9 million outpatient attendances for vision in 2019/20.

Look at the Atlas of variation

New analyses of hospital eye services

The atlas brings together 32 indicators across the whole vision patient pathway, from describing populations at risk of poor eye health, through screening to healthcare services, and health outcomes. It provides new analyses of hospital eye services including outpatient appointments, intravitreal injections, cataract and retinal detachment surgery, and reveals new local and regional variations. This Atlas also brings together key information for local areas on actions that can be taken to tackle the key risk factors for eye disease – preterm birth, smoking, obesity, physical activity, and diabetes.

Bernie Chang, President of the Royal College of Ophthalmologists explains:

‘This new ‘Vision Atlas’ by Public Health England (PHE) provides important data which should help reduce unwarranted variations in the quality of care and health outcomes for patients with eye diseases. We know that rising outpatient activity continues to pose significant pressure on capacity for timely service provision, and that this has been exacerbated by the challenges of the pandemic, increasing the risk of adverse outcomes for patients. In 2019/20 there were 9 million outpatient attendances for vision in England, up by over a third (37.6%) in the last decade. Due to the challenges of the pandemic, in 2020 hospital outpatient attendances for eye health fell by 29%. This ‘Vision Atlas’ should significantly help commissioners and providers working to rapidly recover eye services and drive forward solutions. Now we have the facts, all eye care providers must collaborate to ensure patients are seen in as timely a manner as possible’

Understanding the context

This Atlas presents data and advice to support CCGs, ICSs, commissioners and providers in tackling the key issues in eye care to support the National Eye Care Restoration and Transformation Programme to rapidly recover eye services and to drive forward long-term developments and solutions to improve services and cater for future demand. As a result, up to date analysis is presented alongside information on the context, reasons for variations, options for actions and resources for healthcare providers and commissioners.

Key themes in the ‘Vision Atlas’

Increasing demand on ophthalmology over time

The report highlights a number of statistics showing the increasing demand on ophthalmology over time. Importantly it also says ‘The rising outpatient activity has posed significant and increasing pressure on capacity for timely service provision, resulting in delays for follow-up appointments and increasing the risk of harm and adverse outcomes for patients.’

● In 2019/20 there were 9 million outpatient attendances for vision in England, up by over a third (37.6%) in the last decade.
● The England rate of admission to hospital for all cataract surgery in people aged 65 years and over increased by 16% from 2014/15 to 2019/20.
● In 2019/20, 3.4 million people attended a vision outpatient appointment. The over 65 age group made up 51% of all vision outpatients, this age group makes up 17% of the population.

Workforce shortages

Quoting data from RCOphth and others, the Atlas illustrates the ‘shortage of consultant and specialty training posts required to meet the increasing demand for specialist ophthalmic care’.

● RCOphth estimated in 2018 that an extra 203 consultant posts were required within two years to meet the demand for services in England. The figures for March 2021, with 1,378 posts in England represented only an increase of 118 from April 2018
● The rate of ophthalmology and medical ophthalmology consultants in England has increased, from 1.7 consultants per 100,000 population in September 2009 to 2.5 per 100,000 population in March 2021. The RCOphth estimated for hospital units an ideal consultant rate of 3 to 3.5 per 100,000 population. Across England the rate varies by NHS region from 1.8 per 100,000 population in the East of England to 3.1 per 100,000 in London
● The RCOphth 2018 census also highlighted the need for increases in specialty doctors, staff grades and associate specialists (SAS doctors) and specialty registrars. However, numbers of SAS doctors only increased by 1.7%, 40 posts, from April 2018 to March 2021, 59 below the increase of 188 posts the RCOphth recommended for England
● The number of ophthalmology specialty registrars have fluctuated between 670 and 830 since 2009 with no clear trend, with 296 registrars in March 2021. The RCOphth commented there are insufficient specialist trainees to fill future posts and meet the expected demands of the service.

COVID-induced backlogs

There is useful data to show that there were significantly fewer appointments and operations in 2020 (in the pandemic)

• In 2020 there were 6.5 million all vision outpatient attendances, a 29% fall from 2019
• In 2020 there were 1.4 million all vision outpatient first attendances, a 38% fall from 2019
• Cataract surgery decreased by over 40% in the year 2020 compared to the previous year. In 2020 there were 227,000 admissions for cataract surgery compared to 392,000 in 2019.

Actions for systems (CCGs/ICSs) to reduce unwanted variation

The report recommends that information within the Atlas should be used as ‘a starting point for CCGs to examine their local outcomes, the quality of their eye services, and to benchmark themselves against other CCGs and the national average’. It also points to ‘significant data gaps…the mandated data collection for outpatient activity is not as detailed as inpatient care. There is no mandatory requirement for hospital episode statistics outpatient episodes to be coded by diagnosis (ICD10) or by procedure (OPCS4).


The report shows how worse eye health is linked with other indicators, such as ethnicity and deprivation.

● People of Black African and Caribbean ethnicity are at a 4 to 8 times greater risk of developing open angle glaucoma, the most common form of glaucoma in the UK
● People of South Asian and Black ethnicity are at a significantly higher risk of diabetic eye disease
● People of South Asian and Black African and Caribbean ethnicity have double the prevalence of clinically significant macular oedema and sight threatening diabetic retinopathy compared to the white population with type 2 diabetes
● People of Asian ethnicity have a greater risk of developing age-related cataracts with some evidence of an earlier onset of the disease.
● Studies show that there is a link between low income and sight loss; 48% of people with sight loss say that they live in a household with a total income of less than £300 a week, compared to 19% of people with no sight loss. People with low vision are more likely to live in more deprived areas.

The RCOphth has other useful resources here:

Joint vision for eye care services. Here: Joint vision

Joint Interim recommendations for patient discharge following routine uncomplicated cataract surgery. Here: Cataract surgery recommendations

Cataract Services Workforce Guidance and calculator. Here: Cataract workforce guidance