Capacity issues within ophthalmology are real and current

Eye health in England faces three challenges and maintaining the status quo is not an option.

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Author: David Parkins FCOptom
Date: 1 July 2016

We are facing three challenges for eye health in England: the impact that fragmentation of commissioning and delivery of eye health services has on patient care, the need to implement integrated pathways at scale and the need to collect and use data better so we can measure if we are delivering successful patient outcomes and commission more effectively.

Maintaining the status quo is really not an option...

Our hospital eye services are overwhelmed. There needs to be greater integration between pathways to reduce variation and duplication and eye health needs to be higher up the prevention agenda - particularly in relation to diabetes, smoking and high blood pressure. This is going to require greater use of all available skills across the eye health workforce, starting in primary care. 

New treatments and an ageing population will mean that hospital eye services will continue to be under increasing pressure. Seeing patients on time is the real challenge, often leading to X delayed and cancelled follow up hospital appointments. We can predict the care plan for the cohort of glaucoma and AMD patients, so we should be able to plan capacity across the whole pathway. But this work needs to happen for a large population area (of at least a hospital footprint) and not necessarily on an individual CCG basis.

The Clinical Council for Eye Health Commissioning has brought together groups of experienced clinical leaders and patient advocates to design a series interconnecting frameworks. A fundamental principle is that the patient is managed in the most appropriate service according to risk stratification of the condition and skills of the practitioner. The Community Ophthalmology Framework was sent to Clinical Commissioning Groups (CCGs) last year and the Primary Eye Care Framework has just been published. Low vision services are next on our list.

There is a lack of data around eye health services for the monitoring of quality and performance: the 18 weeks target can only provide an overall measure of waiting times, but some conditions need to be treated much more quickly to save sight.

We need community ophthalmology provision in order to free up hospital eye service capacity. It needs to be integrated with the rest of the pathway and use a multi-disciplinary team of ophthalmologists, optometrists, GPs, nurses and orthoptists to see and treat a wide range of conditions according to the skill set available. The focus being on low risk referrals and stable conditions such as glaucoma and AMD, which could be moved back to the hospital eye services (HES) easily, if necessary. The main purpose is to improve patient flows in the system by managing the vast majority of patients within the community.

Commissioning and contracts need to support change in daily practice. The Primary Eye Care Framework recommends one overall service specification for an integrated service, which includes:

  • a glaucoma ‘repeat measures’ pathway 
  • an enhanced cataract referral linked to post-op assessment
  • a minor eye conditions pathway.

This  will allow for improved access and choice, services delivered consistently across an area, and integrated with the rest of the pathway, so that there would be reduced duplication and waste (fewer inappropriate referrals, better quality referrals and more patients with relatively low risk conditions managed in primary care). Service delivery would be to locally agreed protocols and better data from this service would inform commissioning and delivery plans.

The size of population served by the Primary Eye Care Service in England depends on a number of geographical and demographic factors. However, there are significant financial and operational advantages for groups of neighbouring CCGs to collaborate and commission services to meet the eye health needs of a much larger population. This would include minimising procurement costs. In many cases, it makes sense to design pathways and services so that that referral entry routes to the HES are similar. While community ophthalmology improves flows and creates capacity in the HES, primary care minimises unnecessary referral through monitoring, so there is a greater chance of making savings. 

Eye health pathways frequently cut across boundaries and involve many providers in a network of care. A more co-ordinated approach is necessary to support the integration between services and pathways. With an average population of 1.2million,Sustainability and Transformational Plans (STPs) provide the opportunity for groups of CCGs to work with providers to agree consistent pathways, ideally over an area served by the HES. By working together at a greater scale with clear responsibilities and objectives, there are opportunities for greater efficiency in the commissioning, procurement and delivery of the same service specification by reducing the duplication of effort and the waste of resources. For example, a glaucoma repeat measures pathway is a NICE quality standard, specifically designed to reduce unnecessary referrals to the HES. To have maximum impact, it needs to be followed before any referral for management of suspect intraocular pressures. Having a more consistent approach to eye care pathways will lead to earlier detection of eye problems, and quicker access to appropriate services and treatment, which are so important to achieve better outcomes for patients. Working at STP level will lead to better management of limited NHS resources.

There is a lack of data around eye health services for the monitoring of quality and performance: the 18 weeks target can only provide an overall measure of waiting times, but some conditions need to be treated much more quickly to save sight. We should be reporting on what is happening much earlier in the pathway when there is more chance of saving sight. If such measures were reported in a similar way to the A&E and cancer waiting time targets, specific initiatives and improvement plans might follow. The recent call by the Royal College of Ophthalmologists in their Three step plan for monitoring and reporting on delays for review appointments is very timely and should be acted on. The Clinical Council for Eye Health Commissioning has also endorsed the portfolio of indicators developed by the VISION 2020 UK Ophthalmic Public Health Committee which has a follow up indicator. 

Whatever commissioners put in place, a fundamental issue remains: the lack of IT connectivity between primary eye care and the HES – the first priority action that the Clinical Council put in the response to the Call to action and something the other nations are at different stages addressing. This is clearly a major barrier to more joined up working. We need an urgent solution to this to support any new models of care. We need greater use of technology, better electronic communication between professions allowing for better feedback of the outcome of the patients referral, thus improving the quality of future referrals, better use of multi-professional teams and virtual clinics, and better electronic systems for clinical management and audit. 

As a CCG lead put it at the first-ever NHS eye health summit last month: 'If eye health is not  a CCG priority, it should be. It needs radical, integrated service design. More of the same will not do'.

David Parkins MSc FCOptom FEAOO
Past President, Trustee, Council Member - London

David was the President of the College of Optometrists from March 2014 until March 2016. He is the Chair of the Clinical Council for Eye Health Commissioning, Chair of the London Eye Health Network and a member of the General Optical Council.

He works in independent and hospital practice in south east London, and works part time as assistant director of quality for the Bexley Clinical Commissioning Group.  He is currently conducting doctoral research into the clinical decision making and the referral practice of UK optometrists.

David is a Fellow of the European Academy of Optometry and Optics (EAOO), a liveryman of the Worshipful Company of Spectacle Makers and has been awarded Honorary Life Membership of Vision Aid Overseas.
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