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«Liberating the NHS: Eye Care Making a Reality of Equity and Excellence Professor Nick Bosanquet December 2010 Table of Contents Executive Summary 3 ...»

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Liberating the NHS: Eye Care

Making a Reality of Equity and Excellence

Professor Nick Bosanquet

December 2010

Table of Contents

Executive Summary 3

Section 1 Improving Healthcare Outcomes – better eye health, 7

less blindness, less public expense

Section 2 Putting Patients and the Public First 11

Section 3 Improving Efficiency and Cutting Bureaucracy 15

in Eye Care

Section 4 Working Models 19 Section 5 New Government Policies: 21 the Opportunities in Eye Care Section 6 Delivering on Equity and Excellence – Making it Happen 25 Annex 1 Public Eye Health Need – a more detailed analysis 27 Annex 2 A Firm Foundation of Primary Eye Care 33 Annex 3 Constraints within Secondary Eye Care 37 Annex 4 Working Models of Enhanced Eye Care 45 References and Bibliography 49 Liberating the NHS: Eye Care Making a Reality of Equity and Excellence Professor Nick Bosanquet – December 2010 Executive Summary Introduction This report demonstrates how community optometry has been at the forefront of delivering high quality, patient centred and cost effective healthcare in accessible community settings over the past twenty years;

and how it can do much more in delivering the Coalition Government’s objectives for more care, better outcomes, and better quality within increasingly restricted resources.

Being a market-driven system, optometry works in partnership with the NHS rather than under its control. As a result the optical sector has expanded significantly in the past twenty years to deliver clinical quality, access, choice and high quality health care to all, in every high-street and community across the UK. Uniquely within the NHS, private and NHS patients both enjoy the same standards of care. They both have the same value to a practice, market entry is open (subject to quality standards) and practices and professionals compete to provide the highest quality service to all comers.

In this NHS market, patients can and do ‘vote with their feet’ and money genuinely follows the patient.

Practices that fail to deliver are not protected, supported by NHS recovery plans or any other form of statefunded support. They simply cease to trade and others, who can deliver the service, enter the market to meet consumers’ needs in their place.

NHS Contract The Coalition Government is to be applauded for keeping a national, market-driven eye testing service outside local bureaucratic arrangements. The challenge now for the new Public Health Service is to encourage regular sight tests, particularly working age adults who fund their own care, to help to prevent longer term visual impairment, blindness and burdens on the public purse.

Since 2008, the commissioning system for NHS general ophthalmic services in the community has become bureaucratic and unwieldy and PCT processes have added significant bureaucratic burdens with no demonstrable gain for patients or the public. An opportunity now exists to sweep away much of this bureaucracy and to return to the more efficient status quo before 2008. There is also an opportunity to centralise payments and streamline costs in the Business Services Authority, rather than have upwards of 80 payments agencies, as part of the Arms Length Body Review and to introduce electronic claims and payments in place of the current paper/postage-based systems.

Avoidable Blindness Visual impairment and blindness are increasing in the UK because of the ageing population. However the UK Vision Strategy, Royal National Institute of Blind People (RNIB) and other visual impairment charities estimate that around 50 per cent of this reduced vision is preventable through regular sight testing.

At the same time new technologies, e.g. for age-related macular degeneration (AMD), have transformed the services and interventions which hospitals can provide - now preserving sight where blindness was once inevitable.

As a result conditions such as diabetic retinopathy, cataract and wet AMD that in the past have raised the spectre of blindness, are now largely treatable when detected early.

The challenge is how to bring these services to the expanding populations who need them at acceptable cost.

Pressure on NHS The NHS is a workforce dependent institution. Inevitably the supply of qualified doctors – and hence hospital ophthalmologists and other staff – is constrained and ophthalmology has had to fight over the years for a relatively small share of the available NHS workforce.

Even on best predictions, over the next twenty years the ophthalmology workforce is going to remain limited, whilst at the same time taking on ever-increasing possibilities for treatment, plus the burdens of medical and other training, and the requirements of working hours legislation.

The evidence produced by the Royal College of Ophthalmologists and in this report clearly demonstrates that, whist demand is set to increase, much of the current workload consists of repeat outpatient appointments for routine check-ups.

Fortunately, both for the hospital sector and the nation, much of this work can now be carried out in the community optometric sector. Most optometrists are skilled to perform routine monitoring (which many patients prefer because they see the same person who is familiar with their condition at each visit) whilst optometrists and opticians with additional qualifications, skills, experience and accreditation (supported by clinical governance) can provide more specialist care. This includes an increasing number of optometrists who are now qualifying as independent prescribers of medicines.





The community optometric workforce has never been, and is not now, subject to the limitations or exigencies of state funding or central planning. It is a market-driven system and the optical departments of universities, College of Optometrists and Association of British Dispensing Opticians can adjust both intake and throughput to respond flexibly and over relatively short timescales to the needs of the sector. If the work is there, the workforce can respond in a flexible and cost-effective way.

Way Forward This paper proposes that community eye care is a model service which already exemplifies the ambitions of the White Paper Equity and Excellence - Liberating the NHS. But it can also do much more to relieve pressure on other NHS services, save money and prevent more downstream expenditure by blindness prevention.

We congratulate the Government on its plans to preserve a national sight testing service available to the whole population (on a fee paying basis but with free NHS care for those on benefits and with particular health needs).

We urge the NHS Commissioning Board to commend to GP commissioning consortia the early adoption of the LOC Support Unit Glaucoma Referral Refinement and Ocular Hypertension Monitoring Pathways (which have been hailed as ‘flawless’ by NICE, and have been endorsed by the Joint Committee of the Royal College of Ophthalmologists and the College of Optometrists).

A number of PCTs have already commissioned these or similar pathways under the Quality Innovation Productivity and Prevention (QIPP) agenda and have realised immediate cost savings following implementation (for example the Manchester scheme detailed in Annex 4).

We also call for the rapid confirmation by NICE of national quality standards/pathways for:

• stable glaucoma management in the community;

• primary eyecare assessment and referral services in the community;

• cataract direct referral and post-operative management in the community;

• low vision services in the community;

• stable diabetic retinopathy management in the community.

Universal availability of these services would have the scope significantly to reduce pressure on hospital eye services, accident and emergency departments and GP services.

These quality standards/pathways can easily be constructed from the successful LOC Support Unit and other local pathways which are already in operation, or by further development working with other interested stakeholders. It would be a simple task for NICE or the Royal Colleges to endorse them on behalf of the NHS Commissioning Board.

Unlike sight testing, these enhanced services would need to be commissioned by GP consortia as part of a continuum with the hospital service. However, just as for sight testing, the country can neither afford nor needs 150 or 300 different pathways. Patient needs and treatment modalities are broadly the same and the operation of varying pathways in adjoining populations simply complicates the picture and increases the potential risk (albeit low) within the system.

The NHS Commissioning Board should therefore:

• commend early adoption of the NICE pathways/quality standards to GP commissioning consortia;

• advise them to consider implementation as soon as possible to reduce pressure within the system, increase the amount of optical health care provided locally and reduce overall costs.

This report is submitted by the Optical Confederation and Imperial College as part of their response to the White Paper Equity and Excellence - Liberating the NHS and as a formal submission to the Comprehensive Spending Review 2010.

The Optical Confederation also stands ready to work on this agenda with the College of Optometrists, the Royal College of Ophthalmologists, the Royal College of General Practitioners and Imperial College and to assist in any other way they can.

This is an opportunity for more and better care at less cost – in the public interest, it should be seized.

Professor Nick Bosanquet Imperial College December 2010 Section One Improving Healthcare Outcomes – better eye health, less blindness, less public expense Challenge of Visual Impairment Today Along with cancer, heart disease and dementia, visual impairment is one of the major health challenges facing the NHS (see Annex 1 for details).

The Royal College of Ophthalmologists (RCOphth) estimate that in England and Wales, around 4.3 million people aged 65 and over already have impaired vision (6/12) in one or both eyes. Of these, 2.4 million have impaired vision in both eyes (RCOphth 2002).

A report by Access Economics for RNIB (2009) projected an increase in the numbers in this latter group (i.e. with impaired vision in both eyes) to nearly 4 million people by 2050 - approximately 5.2 per cent of the total projected population (Access Economics 2009).

Individuals can lose their sight for many reasons. Tackling visual impairment means understanding and addressing the key causal conditions: glaucoma, cataract, refractive error, diabetic retinopathy and macular eye disease. The incidence, treatment options, and impact on the individual of all of these conditions are detailed in Annex 1.

The NHS therefore faces a major challenge to detect glaucoma, cataracts, diabetes and age-related macular degeneration (AMD) early and to ensure these conditions do not unnecessarily develop into irreversible visual impairment across the UK. There is also a need to reach out to those patients who would benefit from a correction of their refractive error, which would greatly enhance their safety and quality of life and help to reduce risks to themselves (e.g. falls – see below) and others (e.g. driving).

Three stark messages arise from the analyses of visual impairment (Annex 1):

• the burdens of eye disease, visual impairment and blindness increase exponentially with age (both for individuals and populations);

• half of this is preventable if caught early;

• health outcomes of eye disease are significantly better if detected and treated early.

Future Challenges Ageing Population The UK population is ageing and ageing rapidly. Over the past 25 years the proportion of the population over 65 increased from 15 per cent in 1984 to 16 per cent in 2009, an increase of 1.7 million people. The next 25 years will see an even higher proportion – 23 per cent of the population - aged over 65 by 2034, supported by a shrinking proportion of working age adults to support them (ONS 2010).

This means that the NHS will need to meet the needs of 16.4 million people aged 65 and over by 2034. (A more detailed analysis is outlined in Annex 1.) Burden of Eye Disease Although all age groups can be affected, the main causes of visual impairment in the UK have a higher incidence among the over 65s. As is clearly outlined in Annex 1, the prevalence of glaucoma, cataract, diabetes, and macular eye disease increases substantially and progressively with age. We can therefore expect a corresponding increase in the demand for NHS eye services. We need to start planning now to do all that we can to slow or reverse this expected rise in visual impairment.

The severity of this future challenge has been detailed by the Access Economics (2009) report (page 44), which

projects the following changes by condition from 2010 to 2050:

• Numbers with AMD will almost double to 890,000 people;

• Numbers with cataract will increase 140 per cent to 600,000 people;

• Numbers with diabetic retinopathy will increase 46 per cent to 93,000 people;

• Numbers with glaucoma will double to 200,000 people;

• Numbers with uncorrected refractive error will double to 1.9 million people;

• Numbers with other eye disease will rise to nearly 300,000 cases.

Blindness The numbers of people registered as blind or partially sighted have continued to increase. From 1982-2000 there was a 41 per cent increase in the number of registered blind people; and a 156 per cent increase in the number of people registered as partially sighted. Since then there have been further increases, although it must be borne in mind that many that meet the clinical criteria for blind and partial sight are not registered.

By 2008 there were estimated to be 1.8 million people with partial sight and blindness in the UK (Access Economics 2009). Individuals with preventable blindness are still losing their sight. The NHS has failed adequately to address this problem to date. The challenge for policy-makers and the UK Governments is to slow and hopefully reverse this trend - a challenge that cannot be ignored.



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