‘Optimal Models of Eye Care’ policy roundtables

Improving eye care commissioning – notes from roundtable meeting

19 July 2017, Leeds

In February 2017, The Royal College of Ophthalmologists (RCOphth) published a surveillance report of patients losing vision due to delays in treatment and follow-up appointments.The research, carried out by the British Ophthalmological Surveillance Unit (BOSU), found patients suffering permanent and severe visual loss due to health service initiated delays; the research showed that up to 22 patients per month losing vision by such delays [[1]].

The College of Optometrists has commissioned research resulting in published papers evaluating different models of primary and community eye care. The recently published ”The Way Forward”(2016) series of reports, highlighting the need for services to adapt to improve efficiency and sustainability ”in the face of such growing disparity between demand and resource”[[2]].

This fifthin 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 minor eye condition schemes. This final policy roundtable focused on how to improve eye care commissioning in England.

Setting the scene

Ensuring patients are at the forefront of considering how to respond to capacity problems is crucial for RNIB. A rapid review of the literature on patient perspectives of minor eye condition schemes was carried out. This led us to three key questions for discussion:

Q1. What is needed to improve commissioning to ensure eye care capacity meets demand to prevent avoidable sight loss?

Q2. Should we seek to secure the holistic commissioning of integrated eye care services across all specialities? What evidence is needed to facilitate this?

Q3. How can we raise the priority of eye care in England?

These questions formed the basis of the roundtable discussion. Presentations from a number of individuals gave additional stimulus to the conversation.

A patient’s view

Helen Lee, a Policy Manager at RNIBfirst gave a brief overview of key learning from the four roundtables to date which have covered:

  • Glaucoma referral and monitoring
  • Neo-vascular Age-related Macular Degeneration (AMD)
  • Pre- and post-operative cataract services, and
  • Minor Eye Condition Services.

Helen outlined how previous roundtables had emphasised how essential it is to put the patient experience at the centre of service design. The following key measures can help to achieve this:

  • Services being streamlined so where possible patients can have the appropriate tests, reviews and treatment all in one visit. This is particularly essential as many patients are elderly and/or unable to drive, so attending multiple appointments can be very challenging for them.
  • Patients being given support to know and understand their treatment regimes, so they are able to adhere to treatment, follow up delayed or cancelled appointments, e.g. such as the ‘Get to Grips With Glaucoma’ programme in Manchester.
  • Innovative models of eye care using the right health professional in the right setting with the right expertise and skills. Building trust amongst professionals both locally and nationally is needed.
  • Currently efficient patient friendly models of care are established by passionate committed clinicians. There needs to be mechanisms established to facilitate the implementation of good practice more consistently.
  • Proper service planning is essential based on eye health needs assessments which anticipate demand rather than responding to the issue of capacity. Inequalities in access and outcomes need to be considered throughout to ensure those most at need of services receive them to prevent avoidable sightloss.
  • Work is needed to change the public’s perception of optometrists so that their expertise in eye health is recognised and a sight test is seen as a health check.
  • Also, the broader eye health work of optometrists needs adequate funding;as currently the retail dimension of optometry is a barrier to accessing sight tests particularly for people experiencing low income.
  • Establishing IT-systems that enable the secure transfer of patient data, sharing examples of good practice such as the IT solutions established for mobile AMD services.
  • Prioritising eye care within health service commissioning and planning e.g. for its inclusion in Sustainability and Transformation Plans/ Partnerships (STPs) priorities, and securing political recognition of the value of eye health and the need for adequate resourcing.

Helen concluded that a collaborative approach is essential to ensure the patient’s experience is at the centre of service design–bringing together non-governmental agencies, health services, health professionals, commercial organisations and most importantly people living with sight loss or at risk of sight loss is needed. By working together we can develop and provide robust and convincing evidence to win the hearts and minds of policy makers and service commissioners.

Q1. What is needed to improve commissioning to ensure eye care capacity meets demand to prevent avoidable sight loss?

Participants made the point that NHS targets and tariffs are driving practice and service provision rather than clinical decision making. One solution might be more clinically relevant targets, a standardised approach led by clinicians.

There needs to be better coding and standardisation of ophthalmology data to provide detailed information to commissioners to facilitate efficient service planning.

Valuable learning can be gained from how other areas of health care, commission, plan and deliver services. The example of the NHS LondonStroke Strategy was discussed which developed specialist high-risk centres and step-down services, by looking at need, reconfiguring services and preventing duplication to ensure an effective care pathway was put in place. It was felt that the current situation of eye care is similar to the early days of the cancer networks and we can learn from the development of the work around cancer services.

It was also felt there is a need to look strategically to plan for sufficient eye care capacity to meet demand for patients regarding their eye care, because failing to meet patient need can lead to an increase in this demand and, also for other areas of health or social care issue e.g. due to falls from sight loss. However, the health system does not currently see these as an eye health issue.

Both government and the NHS need to urgently recognise that patients themselves often see their own eye health as a relatively higher priority than is currently recognised in terms of the impact upon people’s overall wellbeing, including if they are dealing with multiple health conditions.

Effective commissioning of integrated eye care services

David Parkins, from the College of Optometrists and Vice Chair of the Clinical Council for Eye Care Commissioning (CCEHC) gave a presentation on effective commissioning of integrated eye care services across all specialities.

David began with a brief overview of the different health systems across the UK’s four countries, and made the point that despite this variation, they all appear to be grappling with the challenge of an increase in patient demand and the capacity challenge this raises for their eye health services.

David ran through the wealth of guidance that has been produced about the commissioning and delivery of eye care services by NICE, RCOphth, College of Optometrists, along with the CCEHC.

David mentioned recent political interest in eye care services. This includes the work of the London Assembly Health Committee which issued a consultation on Eye health and preventing sight loss in Londonfrom mid-June to 31 July 2017. It will make recommendations to the Mayor of London who has a duty to produce a strategy to promote the reduction of health inequalities among Londoners.

There has also been rising interest in Parliament. Nusrat Ghani MP, the former Chair of the All-Party Parliamentary Group (APPG) on Eye Health and Visual Impairment, led a Parliamentary debate on Preventing Avoidable Sight Loss on the 28th March – the first of its kind for many years. David also cited a5th July written question from Jim Shannon MP (the new Chair of the APPG) to the Department of Health (DH), asking the Secretary of State what they are doing“to promote to health commissioners the role that community optical practices can play in delivering eye care services”. However, the DH Minister’s response just referred to the role of CCGs on decisions about eyecare commissioning, and emphasised NHS England’swork with the CCEHC in developing guidance for CCGs on clinical pathways for eye health.

David referred to the CCEHC’s Framework Principles and made the point it makes clear that “patients [should] be managed in the most appropriate service according to risk stratification of the condition and skills of the practitioner”.[[3]]He also referred to the CCEHC’s “Low Vision, Habilitation and Rehabilitation Framework for Adults and Children”(LVHRS), which: “promotes integration across primary and community care, hospital eye service, education, social care, voluntary services, and stroke, rehabilitation and falls teams to deliver better outcomes, and eliminate duplication and waste of resources.”[[4]]

David highlighted NHS England’sconcernin the “Next Steps on the NHS Five Year Forward View” to reduce unwarranted variations in eyecare that exist for patients across England, which it says: “cannot be explained by differences in health need and are often present between different GPs in the same area and different doctors in the same hospital.”[[5]]This variation is substantiated by the 2017 BOSU-study which shows up to 22 patients per month are their losing vision due health service initiated delays[[6]]. David suggested there is a need to look for standardisation.

The draft NICE glaucoma guidance consultation (June 2017) involvesdischarging a new cohort of patients who are low-risk to primary care, and require a discharge summary going to optometrists and provision for glaucoma repeat measurements to avoid re-referral. This will require joint working between primary and secondary care. However, NICE has evaluated how the repeat measures (Glaucoma Quality Standard) should work in practice but found that patients do not respect CCG boundaries, non-participating practices dilute effectiveness of the standard, and a disproportionate amount of time and resource is spent on commissioning ‘repeat measures’ multiple times.[[7]] Davidsaid this indicates a need to commissionat scale for greater efficiency.

David highlighted the importance of an agreement on sharing patient information between ophthalmologists and optometrists which was agreed by the RCOphth and the College of Optometrists in 2015, this needs to be more widespread in order to modify referral patterns.[[8]]

David concluded by contrastingthe traditional referral route for eyecare with a ‘RightCare’approach [[9]]:

  • ‘Traditional’ - in which GPs have had a central role for patients in referringthem to secondary carefollowing a sight testnormally only every two years. It is characterized by only single appointments, no follow up or repeat measures, it is not an acute serviceand there are minimum recall intervals.
  • ‘RightCare’– involves primary eye care service and a community multi-professional team, managing moderate risk and stable eye conditions in a community setting. It utilisesNHS e-Referrals and has replies to referrals, retains more patients, and is integrated because it considers eyecare in relation to other health conditions/ issues e.g. smoking, falls, stroke and dementia. It also involves an integrated LVHRSbetween the health, social care, charity and voluntary sectors.

David said a RightCare approach would help to keep more people in primary care but this depends upon an effective joint commissioning strategy being in place.

Participants felt that more integrated care is needed with optometry and ophthalmology working together effectively, to avoid duplication and to share patient information, which is in patients’ interests. It was noted that this is already being practiced in London through an e-pilot.

GPs however, remain responsible for prescribing and must therefore remain within the eyecare pathway unless optometristsare allowed to prescribe. This is already happening in Scotland where 300 optometrists can prescribe. This figure may increase and could reduce pressure on GPs. For example, in Lambeth and Lewisham it has led to a 26.8 per cent reduction in first attendances from GPs to ophthalmology. It was also felt that patients would benefit from greater clarity about whether they should go to see their GP or an optometrist for their eyecare, and that a standardised care pathway was needed.

It was also noted that GPs or a Practice Nurse currently are still the main health practitioner that patients go to for their overall healthcare, including eyecare. Although this may change if patients increasingly go direct to optometrists; GPs need support to ensure they provide an accessible service for their eyecare patients.

Community ophthalmology

Tim Manners an Ophthalmologist in York and Clinical Director at Newmedica gave a presentation about whole service ophthalmology.

In 1990 seven ophthalmologists were working in tenlocations around North Yorkshire; compared to 28 consultants working in seven locations by 2017. Over the last fortyyears, the population of North Yorkshire had increased by 25 per cent. The county’s elderly population (people over 65) has increased by 100 per cent and eye disease affects 95 per cent of old people. WetAMD is now treatable and cataract operation rates have increased fromfive hundred in 1968 up to 11,500 operations in 2015.

However, this increase in activity is being provided by fewer centresin acute hospitals – only Sweden has a similar model. This approach began in the 1980s as a centralised anesthesia resource; but anesthesia is now rarely required. Tim said it raises the question about how to de-centralize services which could be achieved by:

  • Accepting less central control
  • Incentivizing ophthalmologists to take on the clinical challenges of running services
  • Partnering with NGOs for finance/investment, and
  • Keeping strong links with regional teaching centres, because it is important not to lose the large expert centres and different employment patterns could be encouraged.

A CCG-commissioned service which provides multi-specialty ophthalmology services could provide benefits to the patient and CCG and enable providers to establish themselves relatively easily. Tim illustrated this with the example of Newmedica which has provided Community Services for nineyearsholds a number of ‘multi-specialty’ contracts and sees 80,000 patient visits ayear.

Tim described the model working as follows:

  • If a patient has multiple conditions the clinical team can cross refer internally to a specialist consultant
  • Personalised treatment plans are used, with planned and scheduled treatment based upon the patients’ wants and needs
  • Sharing of data across treatment which ensures better coordination, and
  • The same clinical teams deliver all of a patient’s care and there is a single point of clinical oversight.

Tim outlined the benefits he sees for patients from:

  • Community locations for all appointments –because it is easy to access, especially for follow up; the clinical environment; it helps ensure access for hard to reach populations; it ‘normalises’ the eye condition; and is easier to promote self-care, and
  • Where apatient has multiple eye conditions, it provides them with – patient-centered coordinated treatment; familiarity with the clinical team which may reduce anxiety; and provides a single point of contact for all follows up or questions.

Tim outlined the benefits he sees for CCGs from:

  • More coordinated patient care, with better patient outcomes, reduced unnecessary appointments, and reduced CCG costs
  • As ‘multiple services’ are included, it reduces the number of contracts (and associated administration)
  • Allows additional providers to deliver the service, without significant contract burden
  • They receive more coordinated data across all their services helping improving commissioner oversite
  • It reduces the burden on GPs and associated health professionals, and
  • Reduces the number of patient ‘drop-outs’.

Finally, Tim outlined the benefits he sees for health providers from this model including:

  • A longer-term investment in people, premises, equipment and economies of scale
  • It can also help develop innovation, share learning across specialties and incentivize better patient-centred care
  • Help promote the development of pathways between specialties and better relationships with community optometrists and the third sector, and
  • Help reduce unnecessary administration and support better data sharing.

Participants discussed key questions which this model raised including:

  • The current role of the NHS as a teaching organisation, the costs the NHS carries to fulfil this function and how this affects its outputs, and whether community ophthalmology could also or instead undertake this role.
  • It would require teaching to be funded within contract specifications; if teaching was funded it could incentivize a change in their business model and make it viable.
  • There may be concerns about the optometry sector ‘cherry picking’ the more straightforward conditions and surgery, with the lowest risk cases kept in the community, and the highest risk cases remaining with secondary care.
  • There may be also concerns about undermining the capacity of acute hospitals; and how to achieve this without detracting from their resource as a centre of expertise.
  • The NHS payment system for eyecare is not cost but tariff based and may need to be renegotiated to meet clinical need. As patient numbers and treatments grow the cost/ tariff model will need to change. CCGs donot currently take a whole system approach which is leading to private providers being used to patch up the system.
  • Another observation was that if community optometry grows it may also reach the limits of its capacity.
  • A concern was also raised that community optometry may undermine the NHS and see a return to a pre-1948 model.

2. Should we seek to secure the holistic commissioning of integrated eye care services across all specialities? What evidence is needed to facilitate this?

Several participants suggested that the best way to innovate to improve efficiency in care is via sub-speciality. One participant felt that the NHS has a poor record of successfully commissioning integrated services across specialities. However, there is a real need for planning eye care services across all specialities.