Ophthalmology Scoping Exercise
Draft Report
CONTENTS
Page- Abbreviations
- Introduction
- Health Needs
- Current Position
4.1.Contracts and Providers Cost and Activity Profile / 7
4.2.Referrals / 13
4.3.Pathways / 16
4.4.Casemix / 17
4.5.Quality and Patient Experience: / 19
4.5.1.Outpatient Cancellations and DNAs / 19
4.5.2.Waiting times / 19
4.5.3.Choose and Book Slot Availability / 20
4.5.4.Local Needs and Priorities (includes NHS Choices, Complaints, PALS) / 21
4.5.5.Serious Untoward Incidents / 23
4.5.6.Service Quality / 23
4.6.Patient Choice / 24
4.7.Incentives to Drive Up Performance / 27
4.8.Workforce / 28
- Service Pressures
5.1.Diabetic Retinopathy Screening Service / 30
5.2.New NICE Guidance for Glaucoma / 31
- Options Appraisal
6.1.Primary Eyecare Acute Referral Scheme (PEARS) / 33
6.2.Glaucoma Referral Refinement and Ocular Hypertensive Monitoring / 34
6.3.Pre and Post Operative Cataract Service / 35
- Recommendations and Next Steps
1. ABBREVIATIONS
AOP: Association of Optometrists
ARMD / AMD: Age-Related Macular Degeneration
CQC: Care Quality Commission
DNA: ‘Did Not Attend’
DRSS: Diabetic Retinopathy Screening Service
GAT: Goldmann Applanation Tonometry
HCC: Healthcare Commission
HRG: Health Resource Group
IOP: Intra Ocular Pressures
LES: Local Enhanced Service
LIS: Local Incentive Scheme
LTHT: Leeds Teaching Hospitals NHS Trust
MYHT: Mid Yorkshire Hospitals NHS Trust
NEHEM: National Eye Health Epidemiological Model
NICE: National Institute for Health and Clinical Excellence
NHS WD: NHS Wakefield District
OHT: Ocular Hypertension
OMP: Ophthalmic Medical Practitioner
OPDR: Ophthalmic Photographic Diabetic Review
PALS: Patient Advice and Liaison Service
PbR: Payment by Results
PCT: Primary Care Trust
PEARS: Primary Eyecare Acute Referral Scheme
PROMS: Patient Reported Outcome Measures
QOF: Quality Outcomes Framework
RTT: Referral to Treatment
SHA: Strategic Health Authority
SUS: Secondary Uses Service
YEH: YorkshireEyeHospital
WDCHS: Wakefield District Community Healthcare Services
WECI: Welsh Eye Care Initiative
WYCSA: West Yorkshire Central Services Agency
2. INTRODUCTION
National Context
The final report of the NHS Next Stage Review, High Quality Care for All, sets out the strategic direction for driving improvements in the quality of care across the health service, in particular, working in partnership to prevent ill health, providing care that is personal, effective and safe. Our vision for primary and community care draws together the main conclusions of the Next Stage Review for community-based NHS services, including eye care services, and sets out a strategy based around four key areas:
- Shaping services around people’s needs and views
- Promoting healthy lives and tackling health inequalities
- Continuously improving quality
- Ensuring that change is led locally
In January 2007, the Government announced the results of the General Ophthalmic Services Review. The review concluded that there is a successful sight testing service, which provides patients with convenience and choice and that this should be built on. The review recognised the potential to develop more accessible, tailored eye care services for patients by making greater use of the skills that exist among eye care professionals who work in primary and secondary care settings, to help diagnose and manage a range of eye conditions. The review also saw scope for greater collaboration between the NHS, social care and the third sector in providing integrated services for patients with low vision problems.
Naturally, national work and policy will shape the direction of commissioning of local services. The 18 week standard has particular significance for ophthalmology services in Wakefield District.
The Operating Framework for the NHS in England 2009-10[1] sets out that from 1 January 2009, the minimum expectation of consultant-led elective services will be that no one should wait more than 18 weeks from the time they are referred to the start of their hospital treatment (unless it is clinically appropriate to do so or they choose to wait longer).
From April 2010 minimum operational standards for Referral to Treatment (RTT) of 90 per cent for admitted patients and 95 per cent for non-admitted patients must be achieved across all specialties without exception.
In addition to the above it is also the expectation of Yorkshire and the Humber Strategic Health Authority (SHA) that all PCTs within the region will further improve RTT waiting times during 2009/10 with 90% of patients being treated within 15 weeks and 50% of patients being treated within 8 weeks.
Local Context
Ophthalmology has historically been a pressured specialty in terms of delivering waiting time targets at Mid Yorkshire Hospitals NHS Trust (MYHT), the main secondary care provider for Wakefield District. Delivering against the 18 weeks standard is a key strategic objective for NHS Wakefield District (NHS WD).
During negotiation of the 2009/10 MYHT contract significant variances between PCT expected demand and MYHT expected capacity were identified. Furthermore, it is expected that the new National Institute for Health and Clinical Excellence (NICE) guidance on Glaucoma and Ocular Hypertension[2], published in April 2009, would result in an increase in referrals into secondary care and additional pressure on the limited capacity within MYHT. Therefore, in addition to ophthalmology being a pressured specialty, there are further factors that could place the service under increased pressure.
Wakefield representatives took part in a ‘Route to a Solution’ exercise in early 2009 with Kirklees Primary Care Trust (PCT) and MYHT which explored possible approaches to reduce the pressure on capacity at MYHT. Although elements of work have been undertaken within aspects ophthalmology, there has been a lack of understanding of the local need and complete ophthalmology system in Wakefield District across all providers, both primary and secondary care.
The purpose of this report is to:
- Provide an understanding of local need and the complete ophthalmology system in Wakefield District.
- Enable commissioners to have discussions with stakeholders regarding future ophthalmology services and to make informed decisions about service design and commissioning intentions.
- Support achievement of NHS Wakefield District’s strategic objectives on planned care pathways and delivering 18-weeks targets.
- Support an improvement in patient experience.
Information in this report has been drawn from a range of sources including national policy and guidance, published data and documents, information and data held within NHS WD and the knowledge and experience of colleagues within NHS WD.Where possible, national comparator and benchmarking data has been used.
Significant work is being undertaken separately to specify the Diabetic Retinopathy Screening Service (DRSS) therefore, the analysis in this report does not include DRSS.
A new hospitals development project will lead to the opening of new hospitals in Pontefract and Wakefield in 2010 and 2011. Therefore, it is important that any decisions on future eye care services take account of the new hospital plans and associated capacity.
It is accepted that there are a range of stakeholders who will be able to provide additional context and data to this report. However, it is aimed to be a tool to enable further discussion. Suggested recommendations, based on the information analysis, are made throughout the report to stimulate further discussion.
3. HEALTH NEEDS
A Rapid Health Needs Assessment[3] has been undertaken in relation to ophthalmology in Wakefield District. This report should be read concurrently with the needs assessment. This report does not seek to replicate the level of detail in the document but summarises here some of the key findings.
The Wakefield District has a resident population of approximately 322,415 people. Projection figures suggest that the total population is expected to grow to around 337,500 by 2017. The population is also forecast to grow in line with England, rising 2.17% over the next five years4. There are marked expected increases in the over 65 and over 80 populations[4]which will have significant implications for ophthalmology services which are used more by people in the older age groups.
The National Eye Health Epidemiological Model (NEHEM)5 and 2001 Census data has been used to derive approximated prevalence of ophthalmic conditions. By applying Office of National Statistics population projections to this model it is possible estimate the predicted increase in conditions due to demographic growth.
Table 1: Estimated Prevalence Rates for Key Ophthalmic Conditions
Area (2001) / AMD Cases / NV-AMD Cases / Geographic Atrophy Cases / Drusen Cases / Mean Estimated Glaucoma Cases / High Estimated Glaucoma Cases / Low Estimated Glaucoma Cases / Cataract High / Cataract Low / Impaired Vision / Low Vision / Severely Impaired SightY&HSHA PCT Average / 2.39% / 1.69% / 0.84% / 11.04% / 1.42% / 2.01% / 0.87% / 6.70% / 1.84% / 3.96% / 3.38% / 0.58%
Wakefield District / 2.28% / 1.61% / 0.80% / 10.83% / 1.35% / 1.90% / 0.82% / 6.47% / 1.74% / 3.78% / 3.24% / 0.54%
Source: NEHEM (2009), Public Health Intelligence Team (2009)[5]
The needs assessment outlines projected need for ophthalmic services, both in terms of numbers and percentage, in 2008, 2010, 2015, 2020 and 2025. This information is broken down by the conditions Age-related Macular Degeneration (AMD), Glaucoma, Cataracts and Low Vision with associated impacts on the projected need and limitations of the data. A summary of the projected need is presented below.
Table 2: Projected Need for Key Ophthalmic Conditions, Wakefield
Year / AMD Cases / NV-AMD Cases / Geographic Atrophy Cases / Drusen Cases / Mean Estimated Glaucoma Cases / High Estimated Glaucoma Cases / Low Estimated Glaucoma Cases / Cataract High / Cataract Low / Impaired Vision / Low Vision / Severely Impaired SightWakefield 2001 / 2.28% / 1.61% / 0.80% / 10.83% / 1.35% / 1.90% / 0.82% / 6.47% / 1.74% / 3.78% / 3.24% / 0.54%
Wakefield 2008 / 2.35% / 1.66% / 0.82% / 10.94% / 1.43% / 2.02% / 0.88% / 6.50% / 1.77% / 3.91% / 3.33% / 0.58%
Wakefield 2015 / 2.38% / 1.68% / 0.82% / 11.06% / 1.52% / 2.15% / 0.93% / 6.73% / 1.86% / 3.96% / 3.38% / 0.59%
Wakefield 2025 / 2.68% / 1.90% / 0.92% / 11.83% / 1.69% / 2.41% / 1.05% / 7.80% / 2.28% / 4.47% / 3.79% / 0.68%
Source: NEHEM (2009), Public Health Intelligence Team (2009)5
The projected need shows that the prevalenceacross all conditions is predicted to rise. Therefore it is expected that demand for associated ophthalmic services will also increase.
The needs assessment highlights that smoking, nutritional malnourishment and hypertension may also impact on the level of need for ophthalmic services. Furthermore a rise in obesity and associated diabetic retinopathy would also affect the prevalence of visual ill-health.
The diabetic population of Wakefield is currently just over 15,000 representing 4.2% of the general practice registered population with an expected growth rate of approximately 7.0% per annum[6].
The needs assessment draws the following conclusions:
Wakefield’s ageing population is likely to place additional strain on Ophthalmology services over the next 25 years. Projections of future need are currently crude and do not take account of other extraneous and contributing factors. True need is likely to be in excess of the projections in this document.
In comparison to other areas, Wakefield District is not estimated (by the NEHEM modeller) to have a higher level of need than that of other SHA organisations. While prevalence estimates are relatively close between neighbouring areas, Wakefield is consistently regarded as having a lower level of need on each of the NEHEM outputs. While some of this difference can be perhaps attributed to having a comparatively smaller Black and Minority Ethnic (BME) population, the reliability of the modeller will always be subject to questioning.
Although the estimates of population need defined by the NEHEM modeller may be lower that that of other areas in the Yorkshire & Humber region, the true extent of ophthalmological needs may be more than what is covered by the modeller. The four major eye conditions may contribute the greatest use of resources, but other conditions should be examined for their impact on service usage.
Unmet need in visual problems (based on the definition found in the lifestyle survey) increases with age, although the percentages in men of all ages (except post-75) are higher. While there is not sufficient evidence to suggest why this may be the case, there is evidence at a national level that men are often reluctant to enter into treatment – particularly where preventative treatment is concerned. That need is higher in Wakefield North, Wakefield East and Knottingley.
4. CURRENT POSITION
4.1. Contracts and Providers Cost and Activity Profile
Looking at the contracts that NHS WD holds helps us to understand the providers that we have and the associated cost of services for eye care services. Activity and cost data has been summarised for primary and secondary care services with actual figures for 2008/09 and planned or estimated figures for 2009/10.
At present, PCTs do not hold the budget for primary optical services, such as eye sight tests. These services are funded from a national budget which is administered by West Yorkshire Central Services Agency (WYCSA). NHS WD holds contracts with a number of optometrist practices and these practices are authorised to provide NHS services in line with demand and so they do not have set contracted levels of activity for the year.
Table 3: Summary of Total Activity and Cost
2008/09 (Actual) / 2009/10 (Planned)Activity / Cost (£) / Activity / Cost (£)
Secondary Care / 45,890 / 6,246,574 / 34,870 / 5,001,432
Primary Care / 120,634 / 3,212,562 / - / 3,692,434
Other Costs* / 1,555 / 613,516 / 1,157 / 538,471
Grand TOTAL / - / 10,072,652 / - / 9,232,337
* Other Costs include ARMD injections and fee paid to optometrists for cataract referrals
Note: This report does not include activity and costs for DRSS
Source: Summary Table - see tables below for individual sources
In 2008/09 eye care services in Wakefield District cost £10.07 million. Contracts and estimated levels of activity for 2009/10 have a planned cost of £9.23 million. However, it should be noted that actual activity data for 2009/10 shows that secondary care and Age-related Macular Degeneration (ARMD) activity is exceeding planned activity. Therefore, actual costs in 2009/10 are forecast to be higher.
Summaries of activity and costs for primary care, secondary care and additional spend on ARMD and cataracts referrals are provided in the tables that follow.
Secondary Care
The national mandatory Payment by Results (PbR) tariffs for 2009/10[7] determine the price that secondary care providers will be paid for outpatient and admitted patient activity. The tariffs for ophthalmology services are listed in appendices 1.1 - 1.2.
In 2008/09 the total cost of ophthalmology services in secondary care was £6.25 million. Of this, £3.59 million (58%) was for admitted patient care with the biggest proportion £3.39 million (54%) being on day case activity. Outpatient care accounted for £2.65 million (42%) and this was split roughly equally between the costs of first and follow-up attendances.
MYHT is NHS WD’s main provider of secondary care ophthalmology services. In 2008/09, £5.00 million (80%) of the total cost of secondary care services was with MYHT. The next two biggest providers in 2008/09 were LTHT (£580k) and Birkdale Clinic (£426k).
Detailed information on contracts, providers, activity, costs, including breakdowns by points of delivery can be found in appendices1.3 – 1.10.
1
Table 4: Summary of Secondary Care Activity and Cost
Mid Yorkshire Trust / Other NHS Trusts / Birkdale Clinic / TOTAL2008/09 Actual / Activity
Actual / Cost
Actual (£) / Activity
Actual / Cost
Actual (£) / Activity
Actual / Cost
Actual (£) / Activity
Actual / Cost
Actual (£)
Admitted Patient Care / 4,009 / 2,778,918 / 539 / 526,458 / 459 / 289,074 / 5,007 / 3,594,449
OutpatientCare / 33,505 / 2,219,052 / 4,981 / 295,889 / 2,397 / 137,184 / 40,883 / 2,652,125
Grand Total / 37,514 / 4,997,970 / 5,520 / 822,347 / 2,856 / 426,257 / 45,890 / 6,246,574
2009/10 Planned / Activity
Planned / Cost
Planned / Activity
Planned* / Cost
Planned* / Activity
Planned / Cost
Planned / Activity
Planned / Cost
Planned
Admitted Patient Care / 3,850 / 1,703,110 / 436* / 442,691* / 430 / 273,605 / 4,716 / 2,419,406
Outpatient Care / 23,235 / 2,139,032 / 4,359* / 260,684* / 2,560 / 182,310 / 30,154 / 2,582,026
Grand Total / 27,085 / 3,842,144 / 4,795* / 703,375* / 2,990 / 455,915 / 34,870 / 5,001,432
* 2009/10 planned contract activity for Leeds Teaching Hospitals Trust is not available by specialty therefore ‘actual’ activity and costs figures for 2008/09 have been added to the planned contract activity of the other NHS Trusts
Source: SUS, Provider Activity Returns and 2009/10 Contracts
Other NHS providers of ophthalmology services for NHS WD are:
- Bradford Hospitals NHS Trust
- York Health Services NHS Trust
- Sheffield Teaching Hospitals NHS Trust
- Doncaster & Bassetlaw Hospitals NHS Trust
- Leeds Teaching Hospitals NHS Trust (LTHT)
- Calderdale and Huddersfield NHS Trust
- Sheffield Children's NHS Trust
- Hull and East Yorkshire NHS Trust
1
MYHT Contract
In 2008/09 the total activity at MYHT was 4,364 under the planned level but there was still an overspend of £323,601due to overperformance in admitted activity and the higher than planned cost of out-patient procedures.
During 2009/10 contract negotiations MYHT disclosed maximum capacity of 11,109 first out-patient attendances. NHS WD, as lead commissioner for the trust, mapped the impact of this restriction on follow-up and day case capacity and attributed the shortfall proportionately across all commissioners. For NHS WD the variance between PCT expected demand and MYHT expected capacity for ophthalmology, is estimated to be 3,984 firstout-patient appointments (77 per week), 9,164 out-patient follow up appointments and 1,300 day case episodes. This is a shortfall of 36% for out-patient appointments and 34% for day cases. A total financial value of £1.73 million has been removed from the NHS WD contract with MYHT.
Although this shortfall in activity was removed from the contract for 2009/10, forecasts based on the first 2 months of activity data for 2009/10 show that activity levels have not reduced. If the trend were to continue for the full year, 2009/10 volumes of activity would be equivalent to the expected level of demand rather than planned volumes in contracts, based on capacity. This reflects that sufficient alternative arrangements and providers have not been put in place to meet the gap in capacity at MYHT.
Birkdale Clinic Contract
Birkdale Clinic is an independent healthcare provider, which provides predominantly ophthalmology services. As the tables above show, Birkdale Clinic has been a significant provider of ophthalmology services for NHS WD with a planned contract for 2009/10 worth £455,915. In 2008/09, 9.17% of the total admitted patient care and 5.86% of the total outpatient care for NHS WD was provided by Birkdale Clinic.
Due to problems identified in a Healthcare Commission Inspection Report, the PCT suspended the contract with Birkdale Clinic on 7 December 2007. It was reinstated on 23 April 2008 following a further Healthcare Commission Inspection which demonstrated improvement. During the suspension period the provider was only permitted to see follow-up patients.