NOC 2017 notes

Paul Sidhu, Secretary Dudley LOC

Thursday 9th November 2017

Introduction by Alan Tinger

One-day conference instead of two has been well received

Patients are losing their sight due to delays in care. Optometry can play a major part in helping

Richard Whittington

Where we are and where we are going:

There have been changes in commissioning environment, and the surprise general election has had its effect.

LOCSU managed to get MECs commissioned or a written intent to commission up from 30% to 55% of CCGs

Over the past year, there has been double the number of patients seen, and £7.2 million in revenue for optometry.

Now 19% of CCGs are signalling intent to commission low vision services.

LOCSU have been promoting the profession, including looking at synergies with pharmacy.

Services optometry are providing are verified as clinically robust and patients really like them.

LOCSU also involved in:

  • PCSE
  • Health policy and consultation
  • Public affairs representation
  • CET review
  • Clinical Council
  • Day-to-day office support for LOCs

LOCSU’s Aims going forward:

Support LOCs and Primary eyecare companies

Deliver 80% of CCGs with MECS or a written intent to commission in the next year. This is difficult as commissioning process has stalled due to STP implementation.

Develop and deliver Community Monitoring Services (formally known as Step Down Services).

Changes in Terminology:

Old Terminology / New Terminology understood in NHS
Enhanced Services / Extended primary care services
Community Services / Services delivered outside of hospital
Shared care / Services delivered by primary care in partnership with hospital
Step-down care / Community monitoring or Primary care-based management

Make Primary Eyecare Companies model sustainable and credible: We need to increase size of Primary Eyecare Companies to match the increase in area of commissioning the STPs are producing. This is already happening. In the Midlands, the PEC was set up with foresight and so already has this with all the Black Country, Birmingham and Solihull together. It will continue to monitor the situation. Mergers elsewhere will reduce cost and increase concentration of expertise. Eventually LOCSU want to get cross STP commissioning, so schemes would cover large areas which would solve a lot of cross border problems and makes us look more organised if only one organisation is involved on the optometry side.

Challenges:

CCG to STP to ACO, what will it mean? Due to the election STPs never fully realised. ACOs(Accountable Care Organisations) are local groups of NHS organisations including CCGs covering a STP area, the relevant hospital trusts etc. There is a drive to make STPs into ACOs. Supposed to be a more effective and accountable commissioning body/business model/care model. However, it may mean that as Acute trusts start to have more input in commissioning decisions this will perhaps may make it more opaque. There is some movement in Greater Manchester in this area but it’s still early days to give a clear picture of how this will work from a practical point of view.

Clinical Governance challenge. CCGs are obsessed with this, and we need to ensure that services PECs deliver meet these expectations.

Service delivery skill mix needs to be maintained and worked on.

CQC and NHS standard contract. The contract implies that any company used to commission a service is CQC registered. This being tackled nationally, and it’s also important to separate GOS from this.

PEC company administration needs to be tight, and we must be able to demonstrate that accountancy and company governance are credible.

IT development. Now clause in new Acute Trust contract which means the Acute Trust must only accept referrals only electronically via the NHS spine. Up till now we have always had a way to get round this. LOCSU have 10 months to crack this. There has been some work done in Greater Manchester to inform how this may be done.

As a profession, it doesn’t matter if you are a small independent or large multiple we all want to achieve this and we need to move together.

GOS is currently a non-capped national budget but by getting PECs organised we can be prepared if there is local commissioning of GOS. Due to Brexit taking up parliamentary time it is difficult to pass primary legislation in this area at the moment, so its unlikely to happen in the short to medium term. What will happen in 5 years’ time though is unknown.

Governance Workshop

This was designed as a fun workshop on company governance (especially how it relates to Primary Eyecare Companies), but I didn’t really get much out of it.

What is governance:

  • System of checks to make sure we are safe
  • Must relate to standards
  • Polices and processes
  • Compliance as a company with rules
  • Offers protection/evidence if you have a complaint
  • Pre-requisite to getting NHS CCG contracts
  • Evidence base that can be demonstrated
  • Demonstrates controls
  • Delegate appropriate responsivities
  • Pre-empts any probable problems, though can never pre-empt all possible problems
  • Assurance
  • Framework
  • Clinical, financial, corporate
  • System by which companies are directed and controlled.

In the NHS and elsewhere there has been an evolution in governance:

  • Shipman- no governance, Shipman got away with murder
  • Staffordshire – governance was in place, but circumvented
  • Enron – no effective financial governance
  • Barings Bank – one person able to bring down an organisation
  • Briberies Act – Open, honest, transparent.

Community Glaucoma Monitoring

Predicted rise in glaucoma cases:

  • 22% in next 10 years (18% glaucoma suspects, 16% OHT)
  • 44% in next 20 years

57% of consultants reported an existing backlog.

Number of ophthalmologists expected to remain steady. So, this work has to be done by someone else.

2/3rds of the cost of glaucoma care is spent on clinical care rather than drugs.

How will it work?

  1. Risk stratification exercise is conducted by the consultant i.e. has a patient got low, medium or high risk of progression of glaucoma.
  2. Low/medium risk patents offered community monitoring with phased implementation over 5 years
  3. Patients offered choice of accredited practices, with patient records available to practices electronically
  4. Patients have a clinical review by optometrist who will re-evaluate each time what the individual patients risk of conversion to chronic open angle glaucoma (COAG) and risk of sight loss.

There will be 2 phases to implementation from the optometrists point of view, with 20% of patient available initially, rising to 60% once optometrists have obtained suitable qualification.

There will be a Lead Consultant, Clinical Governance Optometrist and Failsafe officer (to ensure no-one falls through the gaps if they miss appointments etc.)

New Nice Guidelines (2017) continues to talk about trained healthcare professions with suitable qualifications etc., not just consultant ophthalmologists. It specifies the difference between the level of qualification for monitoring versus full diagnosis and treatment.

  • As before, we should refer if there is optic nerve hear damage on stereoscopic slit lamp bio-microscopy
  • ORThere is a visual field defect consistent with glaucoma
  • OR (NEW) IOP is 24 mmHg or more using Goldmann-type applanation tonometry

NEW: Referral decisions should not be based solely on IOP measure by no-contact tonometry BUT if there is no locally commissioned service to pay for Goldmann repeat readings LOCSU suggests we refer but annotate the form that there is no funding for this, hence we have to refer based on non-contact tonometry.

Also, we should no longer refer people who have previously been discharged after investigation for suspect COAG unless clinical circumstances have changed. BUT how will we know when we don’t have access to what the hospital found??

These conditions can be managed in primary care, and should be. All we should have to do is demonstrate governance and competence.

Vision UK update. Keith Valentine CEO

Vision UK strategy: Involves a number of organisations including Vision 20:20, UK vision strategy and other charities. Aims to coordinate their efforts. Focus on patient experience, now want to work out joint strategy. Less talk, more understanding of organisations needed to bring about improvements for patients. Decide on best way forward and path to achieve goals. Concentrate on getting practical benefits. Get investment. Organise voluntary sector better to improve delivery to people with impaired sight.

Beyond OptoManager (OptoManager is the software we use for enhanced services. It is sometimes referred to as Webstar) GianpieroCelino and David Murray

The company involved is now called CegedimRx.

About 210 schemes, activity has increased by about 2x per year since 2014. About 25% (5943) of optical practices using software. Have developed hospital interfaces to allow patients to be seen in community.

New software likely to be made available end of 2018/early 2019 when there will be a transition from Optomanager to the new system.

Move to support “step down agenda” but not sure when and how much activity this will be.

Looking to improve managing change an requests so there is a single process, mediated through optical leads, and consult with LOCSU.

Healthi Services/Healthi Hub is software that will replace OptoManager. It is already used in other countries for GP, Pharmacy etc. It will allow better access to and integration with other services e.g. e-referral, hospital records etc.

Already in use in Greater Manchester Referral program.

In the meantime, will continue to develop the Optomanager program, including new modules in areas that get new services.

It could be a way of rapidly allowing e-referral across optometry if needed if trusts decide to start rejecting non-electronic referrals in October 2018.

The new software is easier and faster to develop and deploy new schemes and make changes to existing schemes.

Already connected to the NHS spine.

Supports standardisation of modules

Has a more modern interface.

Has a GP list that is constantly kept up to date with NHS England data.

A demonstration of the Manchester referral scheme was given. Basically, you input the information that would ordinarily be on a GOS18, but the form alters depending on the reason for referral to gather relevant information. However, currently the NHS insist that the practices have N3 connections to use this.

The improvements in ability to develop and the reduction in variation mean that the fees may reduce.

Primary Care Support England. Paul Dawson, Managing Director

Delivered on behalf of NHS England by Capita.

i.e. the organisation who sort out paying contractors their GOS fees, providing stationary and managing the performers list etc. but also services for GPs, Dentistry and Pharmacy.

Central national model out of 3 centres.

Now at 72% satisfaction rating, from 58% in 2016. They are certain satisfaction will improve as payment accuracy continues to improve, as well as customer support.

CET claim deadline closed the end of October. All claims should be confirmed by the end of November, and payment should occur by the end of the year. You should phone them if confirmation is not received.

Newly qualified optometrists are getting their numbers quicker. Part of the process is approval by NHS England, which can also introduce delays. Can still be held up if the DBS check is not done.

Aiming to replace GOS forms, but ensure they have sufficient stock so there is not a period when neither the old nor new form is available.

Aiming to improve training so more call centre staff can answer queries first time.

Need a change in regulation to allow a digital rather than ink signature. It will still need to be the actual signature, captured electronically e.g. signed on a tablet, touch screen, perhaps scanned.

Looking to introduce eGOS and also a PCSE online form by mid next year. This should improve security, traceability, online validation, ability to track claims and view statements online and simplify the reconciliation process. Moving away from paper forms should reduce postage costs.

Looking to have a set amount of time that it takes to add a new performer/newly qualified optometrist to the performer list. Looking to redesign the form and put it online. Also trying to improve the way it is approved by NHS England Local Team. The application will be able to track the progress of theirapplication online.

For the purposes of the DBS there is a short time limitation in terms of validity, but if you sign up for the online DBS update service at the time it will be renewed, so it is important a pre-reg does this, and makes their application to join the performer list well before they are due to qualify.

If a contractor isn’t getting resolution via email, it is recommended they use the phone helpline. There is a short call answer time. They cannot give a time scale for resolving queries as it depends on the complexity of the query.

They recognise there is too long a delay for new GOS contracts. There are escalation channels.

Still working out how the system would work if a patient attends and is not due, e.g. they haven’t declared having a GOS sight test elsewhere 2 weeks ago. There may not be a way of preventing a test, only flag it to NHS England to investigate the reasons why. This is partly due to data protection issues. However pre-approval for domiciliary testing will probably involve a pre-check of last sight test date.

GOS3 vouchers will be printable as patients may want to take them elsewhere. It will be possible to print them after the date of the test. There is also a way of the receiving practice to check the GOS3 online. This would prevent the double print/use of a voucher.

They expect that paper forms will be in use by some practices for at least 5 years, and there is no plan to stop the use of paper forms currently.

Take Home Messages, Richard Whittington

  • Significant amount of progress over the past year in terms of commissioning development.
  • OptoManger development, and how we might handle eReferrals.
  • Primary eyecare company consolidation is occurring allowing commissioning at scale and more continuity of process between companies. Aims to have comparable services around the country and reduce the costs of Primary eyecare companies to give more money to optical practices.
  • LOSCU need to offer guidance, but understands it can’t be prescriptive. Its role is to support LOCs.

I would say the one day format for the NOC is better as they have to fill the day with serious issues and not waste time on less important things.