Outline Business Case – Service Development

Title of Proposal:
Primary Eyecare Assessment and Referral Service (PEARS)
Author Name and Role: / Name & role of person who will present to the Commissioning Decision Panel: / CCGChair sponsor support agreed:
Date of proposal: / Proposing Organisation(s) & constitution: / Proposed Provider Organisation(s):

[Insert key contact details:]

Executive summary

This proposal is to set up and evaluate a community-based Primary Eyecare Assessment and Referral Service (PEARS).

The proposal supports the national and local strategic priorities of providing care closer to home by moving appropriate work from secondary to primary care settings; evidence based practice and providing patient choice. It also supports the CCG’s QIPP Plan by reducing costs and introducing innovative practice.

A recent survey in Stockport across 8 GP practices[1] showed that approximately 20.5% of patients attend their GP directly for minor eye complaints. GP surgeries are not usually equipped to undertake a detailed examination and in some instances do not have the specialist knowledge. As a result, most GPs currently have little choice but to refer patients presenting with eye problems to the local A&E Department or Hospital Eye Service.

This is unnecessary. The majority of common eye problems can be assessed and treated by local community optometrists.

Patients can be referred to the service by their GP, Pharmacist or Optometrist, or they can self-refer. Assessment and treatment will be undertaken by a number of accredited optometrists within suitably equipped premises locally.

Where referral to secondary care is required, it will be to a suitable specialist with appropriate work up, initial diagnosis and urgency.

Evaluations of PEARS[2] schemes elsewhere in the UK have found:

  • 63% - 75% of PEARS patients can be managed by community optometrists;
  • only 22% need referral to the HES; and
  • 95% of patients were very satisfied with the service.

Savings of around £43,000 per 1000 PEARS referrals are achieved.

1. Description and purpose

This proposal is to set up and evaluate a community-based Primary Eyecare Assessment and Referral Service (PEARS) in [insert name of CCG] for 2 years.

The proposal supports the strategic and operational drivers of [insert name of CCG] as defined in [insert name of document(s) for this CCG – e.g. Commissioning Strategy Plan; Eye Care Strategy; QIPP Plan]. It is estimated that the service will save about £[insert number] pa across the area.

The aim of the service is to use the skills of primary care optometrists to assess, manage and prioritise patients presenting with an eye condition, improving eye care services for patients in [insert name of CCG]

2. Strategic fit and QIPP(See Appendix 6 for National Key Drivers)

This proposal supports the following national and local strategic priorities:

  • Providing care closer to home
  • Moving appropriate work from secondary to primary care settings
  • Evidence based practice
  • Providing patient choice
  • Setting up integrated care pathways

It also supports the CCG’s QIPP Plan:

  • Improving efficiency and reducing costs
  • Improving clinical quality and outcomes
  • Introducing innovative practice

3. The current position

The majority of GPs do not have the training or equipment in their surgery to assess, diagnose and treat many common eye problems. A recent survey of just 8 GP practices in Stockport[3] showed that approximately 20.5% of patients who presented at their GP with an eye related condition would have been suitable for a PEARS scheme.

GP surgeries are not usually equipped to undertake a detailed examination and in some instances do not have the specialist knowledge. As a result, most GPs currently have little choice but to refer patients presenting with eye problems to the local A&E Department or Hospital Eye Service.

Current provision is usually through one of the following referral routes:

  • Optometric referral via the GP to secondary care-based services; or
  • GP referral to secondary care based ophthalmic services; or
  • Patient self-referral into secondary care via A&E

This is unnecessary. The majority of common eye problems can be assessed and treated by local community optometrists and, where onward referral is necessary, this can be done with greater work up and an initial diagnosis. In a 2011 evaluation of PEARS, consultation with an optometrist scored consistently high in terms of patient reported outcome measures (PROMs) and showed that patients prefer to be cared for closer to home by a community optometrist.

The current pathway puts inappropriate clinical work and unnecessary pressure on the local hospital. It takes up GP time. It is inconvenient for patients. It wastes resources.

4. Our proposal

Local needs

Applying evaluations of PEAR services elsewhere to the CCG’s analysis of need / our analysis of the CCG population and referral rates [delete as appropriate], we would estimate that [Insert number] people will use this service each year, plus or minus 5%. Of these, [insert number] will be managed exclusively in primary care; [insert number] will be referred on to secondary care.

Evidence of best practice

In England, an evaluation[4] undertaken by Somerset CCG showed that, over an 18 month period, 86% of presentations were managed within the community by optometrists. Between 38-58% patients would have had to have been seen by secondary care if they were not seen under the ACES scheme.

  • The threshold stated by the CCG to make ACES economic was 40%, and so the review supported the cost benefit of ACES.

Evaluation of the PEARS scheme in Wales showed that 27% of patients were assessed and treated / discharged at the first visit, while 36% were given a follow up appointment and successfully managed in practice, totalling 63%. A further 15% were referred on to the GP and only 22% were referred to the HES.

The PEARS Evaluation[5] showed that in terms of Patient Satisfaction-95% of those who accessed the service were very satisfied and 5% were fairly satisfied.

The pathway

A PEARS examination will provide a timely assessment of the needs of a patient presenting with an eye condition. This will be undertaken by a number of accredited optometrists within suitably equipped premises who will manage the patient appropriately and safely.

Patients can be referred to the service by their GP, Pharmacist or Optometrist, or they can self-refer.

Management will be maintained within the primary care setting, as is appropriate, for many patients as possible, thus avoiding unnecessary referrals to hospital services. The criteria for inclusion are based on work elsewhere and will be agreed with the local Ophthalmologists.

Where referral to secondary care is required, it will be to a suitable specialist with appropriate work up, initial diagnosis and urgency.

On conclusion of a PEARS examination the optometrist must complete a PEARS Patient Record form, report to the referring GP, and to the hospital eye service, should an onward referral be necessary.

Clinical governance

Levels 1 and 2 of the ‘Quality in Optometry’ clinical governance toolkit (Appendix 3) will be the benchmark used and each participating optometrist must adhere to the core standards as set out in the toolkit and be able to provide evidence of this to the CCG if requested to do so.

Each practitioner providing this community service will first undergo a defined training and accreditation process provided by Cardiff University which includes a practical skills assessment and a distance learning component.

Each patient will be provided with a patient experience questionnaire on completion of the examination.

PEARS optometrists will follow all relevant CCG policies and procedures as required – to include patient complaints, serious untoward incidents and clinical audit.

In particular, the provider will investigate and respond to any complaint made about their provision of service initially in accordance with their Mandatory/Additional services contract complaints process and in accordance with NHS Patients’ Complaints Regulations. National Health Service (complaints) regulations 2004, No. 1768 and National Health Service (complaints) amended regulations, 2006, No. 2084 and “Safeguarding Patients” 2007.

Registered Optometrists may sell or supply all pharmacy medicines (IP) or general sale list medicines (GSL) in the course of their professional practice, including 0.5% Chloramphenicol antibiotic eye drops. Please refer to the Model Service Specification for a detailed list of available prescriptions.

The benefits[6] of the service are as follows:

For the patient

  • Rapid access to appropriate eye care in local service
  • Less travel time, time off work and related costs
  • More time for questions and answers

For the commissioners

  • Reduction in outpatient referrals to acute hospital services (up to 78% of referrals for qualifying conditions]
  • Consequent reduction in hospital follow-ups
  • Reduced inappropriate use of secondary care
  • Recurrent savings (estimated at £[insert number] pa)
  • Care closer to home in a convenient community setting
  • Patients offered a choice of providers

For the GP

  • Fast access, local primary care based service
  • Quick, local and accurate screening service
  • Simple referral administration
  • Comprehensive reporting for GP about their patient

For the HES and ophthalmologists

  • Fewer inappropriate referrals
  • More accurate referral of patients: sub – specialty will be identified by optometrist
  • Improved communication between primary and secondary care

For the optometrist

  • Improved alliances between optometrists, GPs and the HES
  • Accreditation for the practice
  • Opportunity to identify and share good practice
  • Better use of under-used skills
  • Proper payment for skills
  • Increased job satisfaction

5. Activity andfinancial analysis

Ophthalmology Referrals 2010-11 = [insert local data]

The percentage of ophthalmology referrals estimated to be suitable for a PEARS service is anticipated to be approximately 40%.

Assumptions:

  1. It is estimated that 40% of patients currently referred to secondary care for conditions that would be suitable for referral to PEARS will have at least one follow up appointment.
  2. It is estimated that 36% of patients referred to PEARS will need a follow up in the community and 22% will need referred to secondary care with at least one follow up.
  3. IT/admin costs of £10 per patient have been included assuming that LOCSU approved software is used to capture the clinical data, provide reports on activity and outcomes, and produce invoicing. See Appendix 5 for further details.

Potential cost savings per 1000 referrals

/ £
Current Service
1000 secondary care referrals (£112) / 112,000
500 secondary care follow ups (£65) / 32,500
Total / 144,500
New Service
1000 PEARS assessments + IT/admin fee (£60) / 60,000
360 PEARS Follow ups (£25) / 9,000
220 secondary care referrals (£112) / 24,640
110 secondary care follow ups (£65) / 7,150
Total / 100,790
Savings / 43,710

£112,710 per 1000 patients seen under PEARS can be saved in secondary care costs. This can be used to fund the primary care PEARS service.

Cost of new service in primary care is £69,000; therefore an overall saving of £43,710 per 1000 patients can be expected.

6. Implementation

In preparation for implementing this proposal, we have:

  • developed the new national pathway;
  • identified the local optometrists who would like to participate in the service;
  • prepared accredited training packages;
  • surveyed local premises to ensure suitability and availability of equipment.

Full implementation will take three months from the date of approval in order to:

  • adapt the national pathway to local conditions in discussion with GPs, ophthalmologists and commissioners.
  • deliver training and ensure accreditation;
  • develop communication plan and materials for local GPs, the HES, patients and the public
  • develop monitoring database and audit materials.

7. Risk analysis and mitigations table

Risk / Mitigation
Clinical Risk 1: Delays in cases needing urgent treatment. / Clear local protocols will allow GPs and optometrists to identify cases that should be referred urgently to A&E. All other cases will be triaged by the optometrists within 24hours. Patients will be contacted within 48 hours to and offered an appointment in the community within 2 weeks for non- urgent conditions.
Clinical Risk 2: Inappropriate treatment or referral by optometrists/GPs. / The service is designed to utilise the core competencies and skills of optometrists. To ensure consistent standards among providers, optometrists will undergo a nationally defined training and accreditation process provided by Cardiff University which includes a practical skills assessment and a distance learning component. Management guidelines will be provided for all common eye conditions covered by the service.
Financial Risk 1: Local availability will increase demand (unmet need). / To the extent that the need is real, early intervention will save higher costs later. Community treatment is cheaper than hospital treatment. PEARS will offer a free from charge 5% ceiling in the first year.
Financial Risk 2: Patients and GPs may continue to refer to the HES or A&E if they are not aware of the service. / Local protocols have been established to ensure that any condition that can be managed in the community can be referred back to an accredited practice as happens in other professions such as dental and pharmacy.
A communications plan will ensure that the scheme receives maximum publicity during implementation and periodically thereafter
Other Risk 1: HES may not support the proposal. / The LOC will work closely with the HES to ensure that all valid concerns are addressed. For example, local optometrists will host trainees to ensure they have comprehensive exposure to common eye problems.
The HES will be part of a quarterly audit and review in the first year of operation so that any problems can be addressed as they emerge
Other Risk 2: Patients prefer to attend the HES rather than an Optometric practice. / PEARS supports a seamless service between primary and secondary care, moving services closer to home for the patient and utilising the skills of optometrists within a community setting. Studies have shown that patients prefer to have their care managed closer to home.

8. Contractual matters

The service will utilise the OptoServ IT solution developed by LOCSU and Webstar Health for this national pathway. The OptoServ software automatically generates secure activity and outcomes reports, robust audit data, and referrals and invoices, facilitating performance management of the community services and eliminating the need for any manual data processing.

We offer two models for contract management:

Contracts with individual General Ophthalmic Services Providers

The CCG can commission the service directly from participating community General Ophthalmic Service contractors as a locally community service. Under this model, the CCG will be responsible for paying and performance monitoring contractors on an individual basis.

Contract with LOC Single Provider Company

The CCG can commission the service from the LOC Single Provider Company. Under the second model, (detailed in Appendix 3) the LOC company would provide a fully coordinated and managed service, including payment disbursement to providers.

We will provide a single point of contact for all matters associated with the IOP Repeat Readings service.

We will use the CCG’s standard contractual documents and procedures. This will include mandatory data provision and a remedial period for any performance problems.

We would propose that the service is commissioned for two years in the first instance to allow it to become established and fully evaluated.

We would also propose quarterly performance monitoring meetings with the CCG’s nominated eye care lead manager and clinician in year one to gain the necessary assurance, then, subject to performance, move to an annual review with meetings only by exception.

In Appendix 2, we have suggested a performance monitoring data set, covering activity, clinical, quality and financial matters for the CCG to consider. We would propose that this is submitted to the CCG on a monthly/quarterly basis in arrears, within two weeks of the end of the period. An invoice for the service provided will be submitted at the same time to enable easy reconciliation.

Signed Date

Chair, [insert name] Local Optical Committee

Appendix 1

Detailed Description of Service

Patients can self-refer into the service or be referred by their own GP (or the practice nurse or surgery receptionist), optometrist or pharmacist. There is a list of participating optometrists for the patient to choose from. Optometrists must, within reason, be able to offer an acute PEARS examination within 48 hours of the day that the appointment has been requested (excluding weekends and public holidays) unless it is for routine assessment. Where this is not possible, the patient will be directed to a colleague nearby. The optometrist will need to prioritise the urgency of the conditions presented. For example Flashes and Floaters will need to be seen within 24 hours.

The level of examination should be appropriate to the reason for referral. All procedures are based on the clinical judgement of the optometrist. Management guidelines will be provided for all common eye conditions covered by the service.

A GOS sight test or private eye examination may also be required but it would be unusual for this to be carried out at the same time as a PEARS examination. Practitioners will at all times respect the patient’s loyalty to their usual optometrist and not solicit the provision of services that fall outside the scope of the service. Children under 17 years of age should be accompanied by a responsible adult.

The criteria for inclusion of patients may include the following:

  • Loss of vision including transient loss
  • Ocular pain
  • Systemic disease affecting the eye
  • Differential diagnosis of the red eye
  • Foreign body and emergency contact lens removal (not by the fitting practitioner)
  • Dry eye
  • Epiphora (watery eye)
  • Trichiasis (in-growing eyelashes)
  • Differential diagnosis of lumps and bumps in the vicinity of the eye
  • Recent onset of Diplopia
  • Flashes/floaters
  • Retinal lesions
  • Field defects
  • GP referral

The following cases need to be referred directly to the nearest Eye Casualty:

  • Severe ocular pain requiring immediate attention
  • Suspect Retinal detachment
  • Retinal artery occlusion
  • Chemical injuries
  • Penetrating trauma
  • Orbital cellulitis
  • Temporal arteritis
  • Ischaemic optic neuropathy

Other conditions excluded from the service: