21 September 2021

College responds to a consultation on Future Planning Model in Northern Ireland

We've responded to a consultation on the development of a new Integrated Care System model in Northern Ireland.

Summary

The College responded to a consultation on the development of a new Integrated Care System (ICS) model in Northern Ireland. While we support a system allowing more collaboration across traditional care boundaries to collectively plan and deliver services in the best interest of patients, we are concerned by this proposed new model and the closure of the HSC Board (HSCB) that may lead to a more fragmented approach for eye care. The College will work to ensure GOS remain national.

Our response

Disagree.

The College of Optometrists support a model that would allow more collaboration, integration and partnerships across traditional care boundaries, with organisations, groups and individuals coming together to collectively plan and deliver services and interventions in the best interest of patients.

However, while we agree that the new system should better meet the needs of local populations, it is not clear how the proposed new approach will allow a more consistent and joined-up approach to the planning, provision and commissioning of health and care services. The health and social care system in Northern Ireland already operates in an integrated system under statute. Therefore, we recommend encouraging a culture change by adding a duty to co-operate that would better allow trust and collaboration between stakeholders rather than another wholesale structural reorganisation, which may distract commissioners, managers and health professionals from achieving their core mission.

Having a legal duty to co-operate would ensure that all stakeholders engage constructively, actively and on an ongoing basis to maximise the effectiveness of healthcare plans. They should make every effort to secure the necessary cooperation and demonstrate how they have complied with this duty. As part of their consideration, stakeholders will need to bear in mind that the cooperation should produce effective and deliverable policies on strategic cross boundary matters.

Joint training and development sessions for all health and social care professionals would also help reinforce a culture of integration and collaboration. Despite the obvious synergies between the various professionals, current training systems offer few, if any, opportunities to interact with other related professions. Given the emphasis on multidisciplinary working and co-operation, this system can hinder joint working between health and social care staff. Joint training and education could enable the different professional groups to understand one another’s roles, responsibilities and ways of working, and encourage mutual respect.

Furthermore, we are concerned by the suggested closure of the HSC Board (HSCB), which currently has contracts with over 270 ophthalmic practices across the region to provide General Ophthalmic Services (GOS) for Health Service patients. These are services not provided by health and social care trusts. The HSCB plans and develops a range of special enhanced services that help manage increasing demands for eye care. Its closure and the delegation of commissioning functions at local level may lead to a more fragmented approach (i.e. a postcode lottery).

Optometrists are already working collaboratively in primary care, community, and hospital settings to provide care, helping commissioners maximise the scope for general ophthalmic services and enhanced eye care services for patients, and deliver eye healthcare capacity in accessible locations, rather than relying on overstretched hospital eye services. The new model should build on their competences and experience to improve the collaboration between primary care optometry and secondary care ophthalmology and ensure eye care services are designed around the real needs of patients, which will include growing eye healthcare capacity for an ageing population.

The General Ophthalmic Services (GOS) and special enhanced services are delivered by ophthalmic practices across Northern Ireland, which provides a standardised and equitable eye healthcare offer across the country. Our priority is to ensure that patients continue to receive a high quality and clinically robust service every time they visit an ophthalmic practice and we would welcome the reassurance that the commissioning of primary eye care services would remain national in the ICS model. This will ensure that equal access to, and benefit from, a standardised eye healthcare offer continues across the population.

Moving to local commissioning could create unwarranted variation in access to core eye care services and could reduce provision in some areas, damaging patient care. It is not clear how the delegation of functions to the level of ICS would be supported in practice. We are also concerned that a localised GOS budget could be spent before the end of a budget year, which could lead to a period of time each year where free eye tests are unavailable for some of the population most at risk of sight loss or vision problems.

Finally, the GOS system is driven by patients being able to access the eye care provider of their choice, in whichever convenient location they choose, guaranteeing access for all eligible patients and a standardised service, irrespective of where people live. These patients’ rights to choose should be protected.

We are also concerned by the suggested closure of programmes of work underway, in addition to the closure of the HSCB, as mentioned in paragraph 1.13. A Northern Ireland Eyecare Network (NIEN) was formally constituted in January 2021. It is not clear what would be the impact of the reform on this new Network. The Network is the successor to the Developing Eyecare Partnerships (DEP) Project, which was implemented in 2012 to improve how eye care services were commissioned and delivered in Northern Ireland. The NIEN is hosted by the Health and Social Care Board and aims at reducing “preventable sight loss by ensuring regionally integrated planning, commissioning, delivery, performance management, and funding of eye care in Northern Ireland.” It is our understanding that NIEN, and its precursor DEP, have already benefitted from a culture of integration and collaboration, where all stakeholders work effectively together to delivering agreed, shared, and prioritised outcomes. Any proposed new model of care should maintain these achievements and learn from them. We would also welcome the reassurance that this programme will continue at a national level, as the NIEN is well placed to continue to plan, co-ordinate, and deliver high quality, accessible eye care which aligns with the Programme for Government (PfG) outcomes, including reducing social isolation, inequalities, and improving life chances.

We agree with this list of values and principles. However, setting out joint values and principles will not automatically lead to improved cooperation between stakeholders. 

As mentioned in our response to question 1 above, we recommend encouraging a culture change by adding a duty to co-operate that would better allow trust and collaboration between stakeholders.

Joint training and development sessions for all health and social care professionals would also reinforce a culture of integration and collaboration and could enable the different professional groups to understand one another’s roles, responsibilities and ways of working, and encourage mutual respect.

We also recommend adding a principle to ensure joint leadership and planning are meaningful. Having shared and equal leadership will allow more and better collaboration between multidisciplinary professionals working in primary care, community, and hospital settings to provide care. In the eye care sector, it will also ensure all pathways are led by the highest standards of joint optometry and ophthalmology clinical governance, applied equitably to all who are providing care, and underpinned by patient-centred outcome measures.

This relates to details set out in Section 7.

Agree, with caveats.

It makes sense for local systems to be accountable to the Minister and the Department. Public scrutiny capacity would increase public confidence in the activities and responsibilities of ICSs. However, we would welcome more details on the accountability process.

This ICS model should provide greater transparency and accountability by establishing the basis for the responsibilities of ICSs, clear and consistent processes for governance, and reporting on service implementation, quality and outcomes, at all levels. Having these processes in place across all ICSs would allow regular scrutiny and review of the impact of health services (and their related budgets) at scale.

ICSs cover large geographical areas so it is important to give them the right statutory basis to effectively design and deliver services that meet the needs of their local populations. While this approach builds on existing local areas and relationships, there is uncertainty around what the final structures will be, and this localised approach may create unwarranted variation across the country. We believe that appropriate legislative changes that incorporate the required operating, governance and decision-making arrangements will help strike a balance between providing sufficient clarity on the core functions and responsibilities of ICSs while enabling flexibility to adapt to local needs.

The Minister/Department should be able to encourage and facilitate collaboration but should also have the powers to prevent structural changes that could work against the interests of patients – for instance, where the result will be reduced access to eye health and care.

In addition, while we understand that funding arrangements will be defined at a later stage, we would like to emphasise that it will be crucial to make sure all ICSs receive sufficient funding and a fair share of the health and care budget to ensure they are able to implement the overarching strategic direction in their respective local areas and meet their local population’s needs.

Furthermore, ophthalmic health professionals, including primary care optometrists, should be included in the decision-making process, including when developing the Strategic outcome framework. We would welcome more details on who would be the key representative groups mentioned in paragraph 7.5 and how all areas of primary care will be engaged and involved.  Optometry is an integral part of primary care and having optometric representation on AIPBs would further strengthen the links between the four Family Practitioner Services (FPSs) and further develop the opportunities for integrated and mutually supportive service provision.

All ICSs ruling bodies should include sufficient people with deep first-hand experience of all health and social care professions, including optometrists. It is vital in our view that any new system ensures regular and sufficient input from all professions at all points. This input should reflect the skills, experiences and insights that these professions can bring to the delivery of health and care services.

Including an eye care voice in the AIPB is essential to ensure eye health is connected and related to general health at the point of decision making. Indeed, people with sight loss are more likely to suffer additional health complications, including depression, and are at an increased risk of falls. In an ageing population, sight loss can also increase the risk of someone with dementia experiencing social isolation and anxiety, putting extra strain on the health and social care system.

Ophthalmology is a high demand speciality accounting for 10% of all hospital outpatient appointments. Having integration and involvement of primary eye care would also ensure that AIPBs can make best use of the local workforce – particularly recognising the role that optometrists and other primary eye care professionals can play in increasing eye care capacity, reducing backlogs in secondary care and preventing unnecessary sight loss, often closer to patients’ homes.

Agree, with caveats.

We agree with this approach as local decision making with increased autonomy would allow local areas the flexibility to develop according to their particular needs and circumstances, and meet the needs of their local population.

The strengths of the proposal in relation to eye healthcare is in the aim to integrate health and social care providers. This should enable them to manage patient care more collectively and efficiently, as well as improved joint working with social care including mental health services, which are crucial for people experiencing sight loss.

However, we recommend ensuring that this new system does not lead to increased bureaucracy and overhead costs. It will be important to introduce more consistent and clear mechanisms for public accountability and engagement between all components of the new ICS model, as this would add clarity for both stakeholders and service users.

Furthermore, many unanswered questions remain to understand how the voices and priorities of service users can be most effectively and meaningfully included within the governance and decision-making of ICSs, and how staff at all levels will be supported to effectively collaborate across organisational and professional boundaries. We recommend clarifying the powers the ICS model will have in relation to local organisations and how the new model will be structured to enable mutual support between provider organisations and effective co-operation within all health and care sectors.

As mentioned in our response to question 3 above, ICSs cover large geographical areas so it is important to give them the right powers to effectively design and deliver services that meet the needs of their local populations. While this approach builds on existing local areas and relationships, there is uncertainty around what the final structures will be, and this localised approach may create unwarranted variation across the country. We believe that appropriate legislative changes that incorporate the required operating, governance and decision-making arrangements will help strike a balance between providing sufficient clarity on the core functions and responsibilities of ICSs while enabling flexibility to adapt to local needs.

Agree, with caveats.

See our response to question 4 above.

The proposal lacks details on the Regional Group’s membership and decision-making process. As already mentioned in our response to question 3 above, we recommend achieving a “voice for primary eye care” at the Regional Group level (and subsequently at all levels within the system) by formally including optometrists and other eye care professionals in the decision-making process, ensuring decisions are informed by all available evidence and identified need. Within this model it is essential that individual professional competences are maintained and enhanced, and that all staff have a right to professional supervision and development.

Agree, with caveats.

See our responses to questions 4 and 5 above.

We support any system that would allow more collaboration, integration and partnerships across traditional boundaries, with organisations, groups and individuals coming together to collectively plan and deliver services and interventions in the best interest of patients.

However, this new system should not lead to increased bureaucracy and overhead costs. It would be useful to introduce more consistent and clear mechanisms for public accountability and engagement between all components of the new ICS model, as this would add clarity for both stakeholders and service users. Moving to local commissioning could create unwarranted variation in access to health and care services, and could reduce provision in some areas, damaging patient care. It is not clear how these functions would be delivered in practice.

Since Northern Ireland is a small county, having locality and community levels seems to add to the complexity by having additional layers of unnecessary administration. This could potentially be damaging in particular for rural areas within Northern Ireland.

Finally, ophthalmic health professionals, including primary care optometrists, should be formally included in the decision-making process at all level, ensuring decisions are informed by all available evidence, expertise and identified need. As this ICS model moves to shift the balance of care from the traditional acute setting to one of prevention, early intervention, and promotion and support for self-care, the role of primary care optometrists in offering value-added interventions and making every contact count will be a key enabler. Optometrists in primary care provide almost 500,000 contacts each year via sight tests, and many more via enhanced services and dispensing activities. It is important to include the voice of primary eye care at AIPBs level to ensure the effective contribution of the eye care sector in improving the health and wellbeing of the population.

Agree, with caveats.

See our response to question 6 above.

This model should provide greater transparency and accountability by establishing the basis for the responsibilities of AIPBs, but clear and consistent processes for governance, reporting on service implementation, quality and outcomes, at all levels should be established. Having these processes in place across all AIPBs would allow clearer responsibility for regular scrutiny and review of the impact of health services (and their related budgets) at scale. It is not clear how governance would work. Will the same groups be responsible for service implementation, monitoring outcomes and allocating funding, or will these be separate groups?

Disagree.

We agree that the membership of AIPBs should be sufficiently permissive to best suit their populations needs. It would enable a more flexible collaboration and would enable systems to be responsive in a fast-changing world.

However, we disagree with the proposed minimum membership of the AIPBs. All AIPBs ruling bodies should include sufficient people with deep first-hand experience of all professions, including primary care optometrists. The new system should ensure regular and sufficient input from all professions at all points. This input should reflect the skills, expertise, experiences and insights, which all professions can bring to the delivery of health and care services. It is vital that all community health and care providers, including representatives of primary eye care providers, are directly involved in the planning and delivery of services for local populations. The proposed minimum membership should include a Primary eye care lead. Ophthalmology is a high demand speciality accounting for 10% of all hospital outpatient appointments, and primary eye care has a key role in increasing eye care capacity through more enhanced and advanced services, reducing backlogs in secondary care and preventing unnecessary sight loss.

This would also be consistent with paragraph 10.12. Optometrists are already working collaboratively in primary care, community, and hospital settings to provide care, helping commissioners maximise the scope for general ophthalmic services and enhanced eye care services for patients, and deliver eye healthcare capacity in accessible locations, rather than relying on overstretched hospital eye services. They have the right experience and knowledge to identify the opportunities and address the barriers to provide a sound foundation on which to build a new way of working. This will help ensure that new services are designed around the real needs of patients, which will include growing eye healthcare capacity for an ageing population.

Agree, with caveats.

We agree with this proposal only if limited in time to enable implementation of the new model. However, it is important to ensure there is a fair and transparent process in place to enable all members/representatives of all professions a chance to chair an AIPB, based on their skills and experience and not only based on their professions as mentioned in paragraph 10.12. Other healthcare professionals within primary care should be equally considered and not only GPs.

Those nominated to sit on – and therefore to potentially chair – an AIPB should have the relevant skills and experience to provide a sound foundation on which to build a new way of working, independent of the profession they represent. Many networks, including the NIEN, draw chairing and system skills and experience from across all stakeholders, with no bias, rigid professional representation, or silo working behaviours. All work towards the same common and agreed set of outcomes.  This model should be considered.

We recommend adding a duty for each AIPB to review their chairmanship and membership as work progresses to ensure it continues to reflect the local specificities and deliver its collaborative functions effectively. Fixed leadership (and professional membership) could lead to a rigid approach with the possibility of creating new silos rather than facilitating more co-operation.

In the meantime, more emphasis should be given in the values and principles as set up in section 5 to ensure all views are considered and not only those of Trusts and GPs. AIPBs should - as a minimum - be required to establish advisory committees, with a fair balance of input, for each of the professions involved in the delivery of health and care services and a duty to have regard to its advice and to set out reasons if they decide not to accept it. Forums as suggested in paragraph 12.10 do not seem sufficient to ensure all views are effectively and formally considered and discussed before taking a decision.

Disagree.

As mentioned in our response to question 3 above, it is important to give representatives of all health and social care professions – including at the Locality and Community levels - the right statutory basis to effectively design and deliver services that meet the needs of their local populations. While the suggested approach builds on the existing local relationships, there is uncertainty around what the final structures will be, and this localised approach may create unwarranted variation across the country. We believe that appropriate legislative changes that incorporate the required operating, governance and decision-making arrangements will help strike a balance between providing sufficient clarity on the core functions and responsibilities of ruling bodies at all levels and enabling flexibility to adapt to local needs.

There is little information on how ICSs will make best use of and contribute to the development of both data and workforce planning.  We have set out below why both are important areas to include in the ICS mandate.

Data
As mentioned in section 5.1, all partners will be expected to commit to the gathering, analysis, sharing and use of population level data. This is a good step forward. However, better quality data across eye care pathways is essential. Commissioners cannot make strategic decisions on eye care or properly understand its importance when they have too little data. This crucial evidence will help commissioners understand local demand for eye care and identify any unmet need. Without high quality data, developing innovative approaches to preventing sight loss will be severely hampered.

We need to have an accurate understanding of the population’s needs the system is trying to meet, in order to plan effective and appropriate eye care services.  For example as a first step, the existing data in the General Ophthalmic Services payments systems and hospital clinical systems needs to be collated and used to best inform ICS planning and commissioning. We would then like to see a move towards better quality and more comprehensive data collection at ICS level, which can be used to inform local health and care service provision.

Workforce
It is important to understand how ICSs will be expected to take a role in workforce planning and development to ensure safe and effective services for patients that make best use of local healthcare professionals. ICS need unambiguous requirements to identify workforce gaps and to work with partners to support the training and development of all staff who deliver commissioned services.

For example, pressures on hospital eye departments are immense and growing. Harmful delays to treatment in the hospital eye service were recognised before the pandemic. We need to offer new models of eye care if we are to avoid unnecessary sight loss and meet growing patient needs. Optimising all available skills across eye health professionals and ensuring trust between primary and secondary care are key in delivering these new models of care. Optometrists are ready and well positioned to play a wider role in transforming eye health delivery alongside other health professionals.

Primary eye care professionals, such as optometrists, are well-placed to provide enhanced and shared care services closer to home and to reduce the backlog of delayed outpatient appointments through both referral refinement and autonomous management of certain eye conditions, without additional training.  Many optometrists also have higher and independent prescribing qualifications that enable them to provide autonomous diagnosis and management of low- and suitable medium-risk patients alongside secondary care clinicians. These skills should be recognised and utilised.

Optometrists should be involved locally in co-developing and leading the workforce planning required for effective care pathways. Where there are common development or training areas across broad primary care pathways e.g. governance, audit, service evaluation, it would make best sense for this training to be made available to all primary care professionals, including optometrists.

Submitted: September 2021

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