‘Optimal Models of Eye Care’ policy roundtables



‘Optimal Models of Eye Care’ policy roundtablesPre- and post-operative cataract services in the community Held on 24th May 2017, BristolSurgery is the only effective method to restore clear sight among those with cataracts [1]. The annual number of surgeries performed in England is growing, with almost 400,000 operations carried out in 2014/15 [2], compared to 340,809 in 2012/13 [3]. Going forward, demand for cataract surgery is predicted to rise substantially. Eye care services must adapt to improve efficiency and sustainability to meet growing demand. Following increased emphasis on moving eye care into the community to help relieve pressure on hospital services, new and innovative models of care are being implemented across the UK, to maximise capacity to treat patients.This third in a series of RNIB roundtable discussions brought together a cross professional group of experts [see Appendix 1] to explore how patients can be at the heart of considerations when developing pre- and post-operative cataract services in the community.Setting the sceneEnsuring patients are at the forefront of considering how to respond to capacity problems is crucial for RNIB. A rapid review of the literature on alternative models of cataract care. The review looked for patient perspectives on issues such as time taken to access the service, experience of delays and cancellations, information provision, emotional support and reassurance and how they navigate the pathway. This led us to three key questions for discussion: 1. How can we ensure that quality and patient safety is not sacrificed to improve efficiency? 2. What evidence and information do commissioners need to improve delivery of cataract care?3. How can eye care professionals work together to support the commissioning of effective cataract pathways?These questions formed the basis of the roundtable discussion. Presentations from a number of individuals gave additional stimulus to the conversation. 1. How can we ensure that quality and patient safety is not sacrificed to improve efficiency? Patient representative Sarah White opened the discussion by sharing her cataract surgery experience. Diagnosed with cataracts in 2012, Sarah underwent surgery in March 2016. She was discharged same day, with a date for her next appointment in a month’s time. She was “alarmed” by what she felt was a significant gap before being seen again. Sarah had expected to be assessed sooner, as she’d developed high myopia since her initial diagnosis. Before Sarah could attend the follow-up, she required emergency surgery following a complication of the surgery; she left with four stiches to the eye. Shortly after, Sarah developed pain in the eye and saw a nurse for treatment. Her next follow-up appointment, in May, was cancelled due to the surgeon not being available. After attending a re-booked appointment a few weeks later, Sarah went back again in June to have the stiches removed. It emerged later that only three of the four stitches were actually removed. Sarah went to see a high street optometrist in July as she felt she couldn’t see very well. Sarah described not knowing what to expect and who to go to for help when things became complicated: “everyone thinks cataract surgery is like going to the hairdressers, that it’s a piece of cake, it’s not”. The optician referred her back to the ophthalmologist for additional treatment in August. Overall, Sarah felt there has been no real improvement to her sight following the cataract operation. Based on the information Sarah shared, roundtable participants suggested that perhaps an alternative treatment option may have been more suitable for Sarah’s circumstances. Participants reiterated the need for better information provision to aid decision making.While routine patients make up the majority of cataract cases, roundtable participants agreed that services must be equipped to identify those who don’t fit into the routine pathway. Routine clinics are often devolved to junior staff who have yet to gain enough experience to identify complex cases. Therefore, they need full clinical oversight from experienced ophthalmologists during their training. Paul Ursell, Consultant Ophthalmologist, Epsom and St Helier Hospitals, is producing a scoring tool based on known risk factors to help identify non-routine patients. Changes to the cataract pathway, such as no longer offering an overnight stay or a first day review, can result in an information gap for patients. Information sharing discussions between professionals and patients should be personalised. Had Sarah known more about the risks involved to her then she may not have gone ahead with the surgery at all: “[the information] wasn’t about MY eyes”.To reduce the risk of a situation like Sarah’s happening to others, there was call for better co-decision making tools and processes, to help facilitate informed two-way conversations. Existing guidance on cataract pathways, such as those produced by the Local Optical Committee Support Unit (LOCSU) and the Royal College of Ophthalmologists (RCOphth), was considered to be generally good and useful. However, it is not being applied consistently across the board, often to the detriment of patient experience. Even integrated pathways such as those in place in Wales, where staff are providing personalised information provision, lack consistency across health boards - creating an inequality in service provision.Participants agreed that the ideal pathway involves clearly defined consent-taking processes, such as those in shared care schemes. Those involved with community pathways felt that optometrist-led referrals reduced the number of inappropriate referrals and were of good quality. In one Welsh health board, 90 per cent of post-op care is community-optometrist led, releasing some ophthalmologist time in the process.Trust was considered a key factor if multiple professionals were involved. Some participants were nervous about optometrists’ ability to lead key aspects of the pathways. However, those who had worked with optometrists in shared care schemes felt that the scheme worked well. Nigel Kirkpatrick, Clinical Director, Newmedica, presented the Newmedica cataract model, of which Specsavers are currently investors. Designed to deliver high volume surgery, the model is informed by best practice guidance. Approximately 5-6,000 cataract procedures are carried out per annum across six sites. Upon referral, consultants triage to add patients to the correct pathway. Nigel described how the model prioritises patient experience. For example, information and consent packs are sent before attending the clinic, patient counselling and education is offered throughout, staggered admission times are set on the day of the operation and the surgeon sees each patient pre-op. Post-op, on day one, patients receive a telephone call to check how they are. They are also given access to a 24/7 telephone helpline. Patients then return to the referring optometrist. Participants felt that the emphasis on continuity of care should improve overall quality. The quality of the service meets RCOphth guidance; posterior capsule rupture rates are 1 per cent and the rate of endophthalmitis is less than 1 in a 1000. Future plans include streamlining referral to clinic (reducing GP workload) and introducing telemedicine capabilities with in store pre-op assessment. The upcoming NICE produced cataract guidance will feed into service refinement. The service does not yet train junior staff. Participants felt training of medical staff is essential to ensuring sustainability. Patient satisfaction appears to be high. Participants discussed key points from Nigel’s presentation: Sustainability: 75 per cent of Newmedica’s work is supporting trusts to tackle their backlog. Participants felt that the trusts should focus on finding long term solutions to their capacity issues, rather than outsourcing. Nigel agreed that direct referral into a service that can manage demand is preferable. Scalability: There is a perception among Clinical Commissioning Groups (CCGs) that enhanced pathways are good. However, participants felt that commissioners in England want to know about cost-savings and not time-savings. In Wales, there is no demand for cost-savings evidence. Key stakeholders come together to understand benefits and barriers from each perspective and value time-savings. The discussion then turned to patient satisfaction data. It was felt that the majority of eye care services collect data on patient outcomes and experience and this evidence could be used to prove impact of the service to commissioners. However, RNIB’s literature search found there is little evidence in the way of evaluations and particularly patient experience/outcomes comparing different cataract shared care pathways within the UK, resulting in a lack of evidence to inform local decision making about existing and future services [4].2. What evidence and information do commissioners need to improve delivery of cataract care?Participants felt that we have evidence capturing patient outcomes and experiences of cataract surgery; we have the guidance to design good services, yet we haven’t managed to influence the right people to establish change in England. Michael Austin, Singleton Hospital Swansea, presented on the integrated clinical pathway in Wales. In Wales, there are no CCGs or other commissioning groups. Michael discussed the key points of the service and how it operates:Community eye care, hospital eye care and support services come together to deliver an integrated service. Ophthalmologist led care, identifying non-routine patients, supporting trainees. Care is patient-centred and ophthalmologist led, with full clinical oversight of postgraduate ophthalmologists in training grade posts from consultant ophthalmologist trainers.In the new patient clinic, the proportion of patients who are referred for surgery who then go on to have it is 80-90 per cent. Nurse-led pre-assessment which works well. Professions involved must trust each other’s clinical acumen. Patients are given information leaflets – specifically, RNIB’s ‘Understanding Cataracts’.90 per cent of optometrists in Wales are trained to an enhanced level to refine referrals and carry-out post-op assessments, ensuring a consistent service for patients. Whole Service audits are undertaken to ensure qualityPatient feedback suggests they are pleased with their outcomes. Interestingly, a minority, whilst still satisfied, lacked full understanding of their condition. In addition, Mike discussed the shortfall in hospital appointments in Swansea Hospital. The service is currently delivering 200 fewer appointments a week than needed. The service has calculated that, approximately, it would cost an extra ?1 million pounds a year to meet this shortfall. Mike also highlighted the need to make the best use of the workforce involved. For the majority of people cataract surgery is highly effective. The role of Consultant Ophthalmologist is to ‘spot the rat’ i.e. the person for whom cataract surgery poses significant risk. Participants discussed how we can influence commissioning to improve delivery of cataract care in England, learning from the development of the Welsh pathway. Manchester is currently the only English area with integrated health and social care services. As earlier, participants felt that those involved in integrated health and social care commissioning understand the value of time-savings vs. cost-savings and thus invest in the service. Participants felt that guidance to monitor and capture cost savings is available, however, most services don’t know how to apply it. In Wales, Michael’s service carried out a cost analysis and found a variance of 40 per cent between the most expensive and least expensive patient.Participant’s felt that ophthalmology is not a priority for CCGs and Sustainability and Transformation Partnerships (STPs) in England, whereas, in the Welsh pathway, eye care is a high priority and this message came from the top-down. Participants discussed a desire to establish eye care plans at the STP level and how to go about this – for example, by designating an eye health champion in each area or by establishing a warm contact point in each area to target any influencing work. Due to underfunding, the influencing power of local eye health networks was questioned. Colleagues from Wales suggested that we focus our work on a handful of STPs, going back to basics to ‘get it right’ and building on the achieved success more widely. It was noted that ministers in particular played a key role in creating change in Wales, as well as pressure and awareness-raising from RNIB. There was a consensus that key stakeholders must come together to form one voice to present the case in England. And not just professionals, but people on the ground too. Participants felt that change is happening. For example, Chris Newell, Commissioning, LOCSU, highlighted that whereas previously 25 per cent of CCGs were carrying out pre and post-op care in the community, this figure has now risen to 38 per cent. 3. How can eye care professionals work together to support the commissioning of effective cataract pathways?Paul Ursell presented on commissioning an effective cataract service given the current capacity challenges. Paul works with two CCGs and gave an overview of the set-up of each. Each CCG has different policies on thresholds, training and direct referrals, and went from paying by procedure to block contract payment. Despite the differences, they both seem to work well, with a 75 per cent conversion rate to surgery. Patients receive an information pack prior to the pre-op assessment in both services. Until recently, the cataract pathways within the two CCGs were managed in-clinic by ophthalmologists. Having reviewed the Royal College of Ophthalmologists ‘Way Forward’ report (2016) [5], both CCGs have moved second eye surgery post-op assessment into the community. If that works well, there is scope for Optometrists to lead pre-op assessments as well if the appropriate training is put in place. Participants felt that if multiple services are involved then they must be fully integrated, otherwise pathways risk becoming unnecessarily fragmented. Clear communication mechanisms were considered essential, particularly for sharing training updates. The need to build trust between professions was reiterated. Generally, in comparison with ‘traditional’ models of care, community shared care pathways are considered to facilitate timely assessment of patient needs, reduce inappropriate referrals into secondary care, possibly result in an increase in the skills of the optometric workforce, and ensure the patient pathway is as short as possible with appropriate choice of service access [6]. However, participants shared concerns that patients can fall between the cracks of two services unless clear clinical oversight is in place. The role of good IT systems in this process cannot be underestimated. In Wales, IT was named the biggest barrier to integration. Colleagues felt that this should not be used as an excuse not to improve services and there are workarounds until a proper solution can been found. Electronic record keeping/sharing using reliable IT is essential. Mike Austin, Consultant Ophthalmologist, Swansea Hospital, highlighted that investment in IT may be a necessity, for example, in his service, there is a task and finish group just for overcoming IT related barriers. Paul highlighted that both the CCGs he is working with want to undertake more cataract operations but can’t due to limited space. Due to pressure for more capacity for a range of specialities the hospital began to open theatres for evening appointments and therefore more space was secured for cataract appointments.The use of thresholds was still a major concern. Participants felt that commissioners lack understanding about what the guidance says around use of thresholds. The recently released draft NICE cataract guidelines recommended removing thresholds; if this remains in the final version of the guidance, removing thresholds will create even higher demand. Services will need to further adapt to accommodate this.Next steps: Information from all the policy roundtables will be collated by RNIB for submission to the APPG inquiry into improving eye care commission and tackling capacity issues within eye care services. Prior to this the draft notes from this meeting will be circulated for agreement to attendees. It is envisaged that the findings from the APPG inquiry will be used to formulate a sector wide campaign to improve commissioning of eye care services to better meet the needs of the population.References [1] Royal College of Ophthalmologists. (2010). Cataract surgery guidelines. Royal college of Ophthalmologists. London. [2] Health and Social Care Information Centre. 2015. Hospital Episode Statistics, Admitted Patient Care – England, 2014-15. HSCIC. Health and Social Care Information Centre.[3] Health and Social Care Information Centre. 2012. Hospital Episode Statistics, Admitted Patient Care - England, 2011-12. Health and Social Care Information Centre.[4] Amin M, Edgar DF, Parkins D & Hull CC. 2014. A within the London region. Optom Pract 2014; 15: 29–38.[5] Royal College of Ophthalmologists. 2016. The Way Forward Cataract Report. Royal College of Ophthalmologists. [6] Baker H, Ratnarajan G, Harper RA, Edgar DF, Lawrenson JG. 2016. Effectiveness of UK optometric enhanced eye care services: a realist review of the literature. Ophthalmic Physiol Opt, 36: 545– 557.Appendix 1 Jim Barlow, Chair, Former Head of Primary Care - Staffordshire and ShropshireSarah White, Presenter/contributor, PatientFazilet Hadi, contributor, Deputy CEO, RNIBHelen Lee, contributor, Prevention Manager, RNIBChris Newell, contributor, Commissioning Lead, LOCSUPaul Ursell, Presenter, Consultant Ophthalmologist, Epsom & St Helier HospitalsNigel Kirkpatrick, presenter Consultant Ophthalmologist, NewmedicaMary-Anne Sherratt, contributor, College of OptometristsMike Austin, presenter, Consultant Ophthalmologist, Swansea HospitalPaul Morris, contributor, Director of Professional Advancement, SpecsaversAdele Gittoes, contributor, commissioner, Aneurin Bevan UHB - Corporate ServicesFrank Moore, facilitator, National Service Delivery Manager (NHS), Specsavers ................
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