«THE ROYAL COLLEGE OF OPHTHALMOLOGISTS’ Improving eye health and reducing sight loss – A ‘Call to Action’ Response The Royal College of ...»
THE ROYAL COLLEGE OF OPHTHALMOLOGISTS’
Improving eye health and reducing sight
loss – A ‘Call to Action’ Response
The Royal College of Ophthalmologists (RCOphth) is the professional body for eye doctors,
who are medicaly qualified and have undergone or are undergoing specialist training in the
treatment and management of eye disease (including surgery). As an independent charity, we
pride ourselves on providing impartial and clinically based evidence, putting patient care and safety at the heart of everything we do. Ophthalmologists are consequently at the forefront of eye health services because of their extensive training and experience.
The RCOphth recognises the increasing demand for eye care and the need to work in multidisciplinary teams with other medical and non-medical professionals to deliver high quality
care that is cost effective. This response makes three assumptions throughout:
1. NHS England wishes to tackle health inequalities between different patient groups (eg people with dementia, homeless people and travellers, people with learning disability) and patients from all socio-economic backgrounds.
2. Patients should be able to move seamlessly from primary, secondary and third sector care and back again without compromising care.
3. Access to eye care needs to be more equitable; this must include patients being followed-up for acute and chronic eye conditions as well as newly referred patients.
This Call to Action (CTA) presents a unique opportunity to develop commissioning policies which can improve patient care by developing patient referral pathways and management protocols that are safe and appropriate for patients whether they are looked after in the community or in hospital. These need to be evidence based and fully costed.
Recommendation: CTA should take into account the recommendations of the Dalton review, launched by the Secretary of State for Health in February 2014 (1). Although this will primarily focus on hospitals, we recommend that both CTA and Dalton, are reviewed together so that a coherent management plan across the eye care sector can be implemented.
Recommendation: RCOphth encourage NHS England to support the UK’s Vision Strategy (2) which has broadly similar goals.
2014/PROF/296 10 September 2014 1 Call to Action Questions
1. How can we secure the best value for the financial investment that the NHS makes in eye health services?
The RCOphth recognises that best value is achieved when patients who require assessment or treatment are seen in the most appropriate location by health care professionals who can deal with them effectively and efficiently, whether in the community or in the hospital and that anyexamination, testing and treatments are commensurate with their needs. Therefore it is vital to ensure that only appropriately trained, competent and experienced personnel look after the patients in any setting.
This needs a careful assessment of training needs, construction of new ways of working which will cut across the primary/secondary care interface, and involve the development of safe patient pathways with improved communication and IT services. The true cost of services will need careful financial auditing for cost-effectiveness. The entire team needs to work together to prevent duplication and maximise resources and to ensure that the patient is at the centre of all care provision.
Recommendation: The RCOphth recommends a consultant ophthalmologist-led service following the principles of the Academy of Medical Royal College’s Guidance for Taking Responsibility: Accountable Clinicians and Informed Patients (3).
Increasing capacity The hospital eye service clearly already works efficiently. In England the number of eye out patient attendances increased by a remarkable 30% from 5 million to 6.5 million in a 5 year period (2008 -2012) due to the introduction of successful new treatments and services. This has been absorbed with comparatively small amounts of funding and small increases in personnel because of the early and rapid adoption of new working practices. This has involved developing and implementing new guidelines and training of ophthalmic nurses, optometrists, orthoptists and technicians to work as part of the medical team. This model of extended teamwork using the whole eye health community can – and should – be replicated into care beyond the hospital walls. The appropriate training of non-medical personnel for extended roles in the community following agreed ophthalmology led pathways, networks and shared care schemes will increase the capacity of eye health care. However, this can only occur when an essential communication infrastructure exists to permit free flow of relevant clinical information to reduce duplication of services and to ensure the sharing of appropriate data for efficient care.
This would assist in reducing the number of unnecessary referrals (false positive referrals) to hospital and permit discharge of low risk patients into the community. Both of these elements are key to increasing capacity in hospital eye services, allowing them to focus on the true positive referrals i.e. patients who need treatment. It is important that services are planned according to local needs and any increase in capacity is a long term rather than a short term objective.
The expansion of roles would permit an increase in the capacity of care – both space and personnel – but there is as yet no evidence regarding the cost and efficacy (hence value) of transferring care from hospital to community, even where such models exist eg Wales and 2014/PROF/296 10 September 2014 2 Scotland (see answer to question 12e). The care received in hospital eye service represents the expected standard to be achieved. Overall there are more patients seen in hospitals per unit of time per clinician and more defining clinical decisions made, with fewer unnecessary reviews, due the availability of specialist knowledge. These high volume services utilize personnel and expensive equipment efficiently and should be expanded where feasible.
To create these services:
The training needs of non-medical personnel will need to be addressed (including funding), see Glossary for information on professions involved in the eye care process.
Regular full audit of outcomes to ensure quality, safety and value.
Appropriate IT and communication need to be available in the community.
Recommendation: To meet growing demand increasing and broadening the capacity of consultant ophthalmologist-led eye health care is necessary – this needs to be carefully constructed from the perspectives of training of personnel, cost and patient involvement, and should be evidence based.
Accurate costing of services Tariffs for new and follow-up outpatient visits, necessary tests and treatments should reflect true cost. Commissioners should not enforce arbitrary new to follow-up ratios as this can lead to the inappropriate discharge of patients (4).
With services now offered to Any Qualified Providers, it is clear that under cutting nationally set tariffs or awarding large contracts may have considerable the impact on local hospitals, which are still required for complex care and may result in damage to this infrastructure which would be counterproductive.
Financial incentives for optometrists to refer patients to hospital for certain conditions, such as cataract, should cease as this provides a perverse incentive to refer inappropriate patients for surgery.
Recommendation: Services should be costed properly and accurately in both primary and secondary care with tariffs that reflect these costs.
Data collection to provide evidence to inform decisions There is insufficient information about the overall capacity needs of ophthalmic services in the UK. Patients are waiting for increasingly long periods of time and there are delays and postponements of return appointments and treatments. It is impossible to arrange appropriate services without this information The outcomes of consultations and treatments are also unknown as no data are collected about these activities. HQIP (Healthcare Quality Improvement Partnership) has funded the RCOphth to run a national audit project looking at the outcomes of cataract surgery and the feasibility to also audit outcomes of glaucoma care, retinal detachment surgery and care of patients treated for wet age-related macular degeneration. This will provide vital information that will help to develop services based on patient needs and the optimum use of services.
One of the main outcomes this CTA should be prevention of sight loss. The registration and certification of patients with sight loss (sight impaired or severely sight impaired) would therefore be a highly useful measure of success or failure. However, for any reduction in the rate of certification to truly reflect an improvement in the service, the collection of data must be comprehensive and accurate. The data is currently used to inform the Public Health Indicator Outcome Framework for Health and Premature Mortality for preventable sight loss http://www.phoutcomes.info/. NHS E or Public Health England (PHE) should consider funding the collection of Certificate of Vision Impairment (CVI) data which at present is independently funded (by RNIB). Proper, improved funding may allow electronic certification and registration, reducing the burden of data collection and improve uptake.
Recommendation: Accurate data should be collected regarding the outcomes of patient episodes and pathways to ensure optimum use of resources. This should be supported by mainstream funding.
The use of routine sight tests Vision testing is recommended and is an important method of identifying some eye conditions.
A consistent ophthalmic examination is important and needs to be agreed on to maximise its role and prevent waste.Therefore, the GOS sight test should be standardised with regard to content, frequency, equipment and eligibility. The basic sight test needs to be defined – with clear evidence for the use of each test. If standards of testing and assessment are set, then referral guidelines and follow up of patients by optometrists will be more accessible.
Equipment should be compatible with that of the hospital service in order to provide similar results that can be directly compared with each other. Although routine sight tests have been funded by the Department of Health through the GOS budget for many years, there are no performance indicators or standards and there is no routine audit of costs and effectiveness.
Given the standards which all other NHS services must meet, this should be addressed to ensure good value.
The current GOS sight test fee, despite its recent uplift, still does not cover the actual cost of the NHS sight test. This affects the financial viability of the optometrist and the sale of glasses or contact lenses often subsidises the test. This creates a significant conflict of interest with optometrists under significant pressure to sell as many glasses as possible – even resulting in the adoption of ‘conversion rates’ by some companies.
Therefore, there is a concern that the uptake of GOS sight tests may be less universal because of public wariness that they will be pushed to buy spectacles or pay for certain tests.
Separating the commercial aspects of optometry with sight testing to detect eye disease should be considered. In addition, performing this test in other settings eg GP practices or even in supermarkets may improve access especially in the poorer parts of the community (5, 6).
There should be coordination and cooperation between primary and secondary care so that sight tests can be appropriately done in more convenient locations. Patients who are in the 2014/PROF/296 10 September 2014 4 secondary care system who require tests that can be done in the community should have these done there eg field of vison testing is commonly at breaking point in the hospital and this could be performed in the community. This requires secure IT networking to share relevant data. Data protection and patient confidentiality must be kept so that the clinical information transmitted to the community optometrists will be kept secure and personal.
A register of tests performed should be kept as part of a patient’s health record by the GP.
Likewise, optometrists who look after a patient's eye health should have access to the relevant GP and hospital records (a model being looked at in Scotland). Repeat testing by different optometrists and across the primary /secondary care interface needs to be avoided. The timing and frequency of tests should also be optimised.
Recommendation: The current GOS scheme should be reviewed. The sight test should be standardised, avoiding need for duplication. Separation of the function of early detection of eye disease using the sight test from sales of glasses or contact lenses should be considered.
Commissioning across public health primary, secondary and tertiary care and social services The fragmentation of services promotes a ‘silo’ mentality for funding care. This leads to shorttermism as financial decisions only affect the immediate to medium term and do not have apparent or relevant implications for the future. By commissioning across the entire health and social care pathway, the patient remains at the centre of the process. For example, a drug deemed too expensive in a health budget will be cost-effective when the social cost of losing sight on independence and occupation is taken into account. Full integration of funding would help better decision making.
Recommendation: Close coordination of eye care commissioning should occur across public health, primary, secondary and tertiary care and social services.
New ways of working There are several ways of streamlining assessment and management of patients. Virtual clinics for glaucoma and AMD services have increased the efficiency of clinic time. These utilize technology and non-medical eye health care professionals to assess patients with review of the findings by a consultant ophthalmologist who effects a management plan.