Transformation Directorate

Digital referral, remote support communication system for secure advice and guidance

Manchester University NHS Foundation Trust includes nine hospital sites: Manchester Royal Eye Hospital (MREH), Manchester Royal Infirmary, Royal Manchester Children’s Hospital, Saint Mary’s Hospital, The University Dental Hospital, Altrincham Hospital, Trafford General Hospital, Wythenshawe Hospital and Withington Community Hospital. The Trust is the main provider of hospital care to approximately 750,000 people in Manchester and Trafford.


There is increasing demand on hospital eye services and recognition that some patients who currently attend hospital could be managed in the community by working more closely with primary care optometrists who have access to excellent equipment and offer a high level of expertise in their own practices. However, to take advantage of this there needs to be a secure referral system in place which connects optometrists to consultant ophthalmologists to support them in managing patients and avoiding unnecessary referrals and visits to hospital.

The introduction of the Covid Urgent Eye Care Service (CUES) during the early part of the pandemic provides a clear pathway which can be commissioned using these principles. The ability to share large data image files, such as Optical Coherence Tomography (OCT) scans for retinal disease, allows a very high level of clinical interaction to underpin such an integrated pathway.


To develop a system which can securely communicate between primary care optometrists and secondary care ophthalmologists which also supports image transfer, including large data files such as full volumetric OCT. This would work best if it could provide two-way communication and ensure referrals feed into the e-referral service (eRS) system so that the referral route is not separate from those sent by the GP.

Solution and impact

The Manchester and Greater Manchester locality is served by Primary Eyecare Services (PES), an optometry federation established by local optical committees in England. PES holds contracts with several clinical commissioning groups (CCGs) to deliver extended primary eye care services, including glaucoma, cataract and minor and urgent eye conditions. During COVID-19, the intention was to safely deliver urgent eye care in the community using remote triage and consultations by telemedicine, minimising face-to-face appointments, and making use of technology to allow for advice around referrals via e-RS.

Manchester wanted to do this through a commissioned CUES service and facilitated it by implementing the Optometric Electronic Referral and Assessment (OPERA) system which was deemed crucial to the success of the service.

In the area covered by the Manchester and Trafford CCGs (that is 2 of the 10 CCGs in the Manchester and Greater Manchester area and where MREH is the provider hospital) there were some 1,100 CUES cases seen in the community in June and July 2020, with approximately 87% being retained in primary care and only about 13% referred.

Referred cases had a lower prevalence of the more benign or lower risk acute ophthalmic presentations typical in previous audits on attendance (ie fewer cases of conjunctivitis, blepharitis and dry eye) and identified as often not needing hospital-level input.


Optometric Electronic Referral and Assessment (OPERA) is a secure digital referral, remote support and picture archiving and communication system (PACS) configured to streamline referrals from primary care optometrists to the ophthalmologists in the hospital eye service and provide two-way communication.

It integrates with hospital PACS, PAS, clinical messaging, eRS and other IT systems used in the NHS. Currently OPERA is being used for referrals and advice and guidance primarily for CUES, but also other referrals. The system is also being adapted to accommodate the requirements of a co-management scheme (such as the potential IT system for a primary care Ocular Hypertension (OHT)/glaucoma suspect monitoring service).


  • Optometrists can access summary care records (SCR) for information on general and ophthalmic health
  • Optometrists can look-up the NHS number
  • Direct NHS e-Referral Service for optometrists
  • Picture archiving communication systems for images to be sent and reviewed by primary and secondary care
  • E-referral service enables two-way correspondence between primary and secondary care


  • Digital referrals from optometrists to ophthalmologists directly through eRS, including clinical images and clinical information
  • Allows exchange of large image files including full volumetric optical coherence tomography (OCT)
  • Referral refinement with communication between the hospital eye service and optometrist
  • Optometrist can use technology for advice and guidance to support management in primary care

Key figures/quotes 

Audit of the OPERA-facilitated Manchester CUES service has shown 87% of cases can be managed in the community through advice and guidance.

Find out more website has more on the urgent eyecare service here

Key contact

Matthew Jinkinson, chair of Greater Manchester Local Eye Health Network