Outline Business Case – Service Development

Title of Proposal:
Cataract Referral and Post-Operative Examination
Author Name and Role: / Name & role of person who will present to the Commissioning Decision Panel: / CCG Chair sponsor support agreed:
Date of proposal: / Proposing Organisation(s) & constitution: / Proposed Provider Organisation(s):

[Insert key contact details]

Executive summary

This proposal is to pilot a Community-based pre- and post-operative care of cataract patients, eliminating the requirement for a visit to a GP, providing a comparable service for patients who are unable to leave their home unaccompanied but who are able to attend for surgery.

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 audit in Stockport[1] found that the proportion of patients listed for surgery following referral had risen from 62% to 86% which meant a reduction in unnecessary hospital referrals.

Patients can be referred to the service by their GP or Optometrist, or they can self refer. The assessment will be undertaken by a number of accredited optometrists within suitably equipped premises locally. Savings of around [insert number] per 1,000 referrals can be achieved.

  1. Description and purpose

This proposal is to set up and evaluate a community based Pre- and Post-Operative Cataract Service 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 improve eye health and reduce inequalities by providing access to eye care in the community and reducing the number of visits post surgery to the Hospital Eye Service for patients in [insert name of CCG].

  1. Strategic fit and QIPP[reference national and local documents where possible]

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 pathways

It also supports the CCG’s QIPP Plan:

  • Improving efficiency and reducing costs
  • Improving clinical quality and outcomes
  • Introducing innovative practice
  1. The current position

Currently due to the constraints of a General Ophthalmic Services (GOS) sight test, optometrists refer all cases of cataract to secondary care for confirmation of the diagnosis and treatment where necessary. This works well when the diagnosis is positive and the patient wishes to undergo surgery. However, there is no provision for counselling patients on the risks and benefits of surgery or investigating possible contraindications to surgery.

This is unnecessary. The current pathway puts inappropriate clinical work and unnecessary pressure on the local hospital. It is inconvenient for patients. It does not allow for a proper, informed referral. It wastes resources.

  1. Our proposal

Local needs

Estimated number of patients the service is likely to cover: [insert number].

Data from the National Eye Health Epidemiological model predicts the following for cataract prevalence across [insert name of CCG].

Low Estimate[insert number]

High Estimate[insert number]

Mean[insert number]

Applying evaluations of Cataract 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 would use this service each year, plus or minus 5%.

Evidence of best practice

In England, an audit of the Stockport cataract referral pathway found that the proportion of patients listed for surgery following referral has risen from 62% to 86% reducing unnecessary hospital referrals. [Insert as appropriate]

The pathway

A GOS sight test will reveal the presence of cataract and the optometrist will discuss this with the patient. If the cataract is not presenting any significant visual or lifestyle difficulties then the patient will continue to be reviewed by the optometrist. If the patient does wish to be considered for surgery then the optometrist will provide a self assessment questionnaire which will help to establish suitability for surgery highlighting other health problems and possible contra-indications. The patient will attend for the full cataract assessment to elicit relevant ocular, medical and social information which will assist the HES to ensure patients receive the most appropriate treatment and care. If the patient is willing to undergo surgery and the optometrist considers that they are suitable, then the referral form will be completed and the optometrist will provide the patient with the choice of treatment centres and fax or post the referral and self-assessment questionnaire to the centre.

The post-operative service provides for the assessment and management of patients who have now undergone the cataract surgery in either eye. Patients without complications post surgery will be instructed to visit the referring optometrist after 4 weeks for the final post op examination and GOS refraction. If the patient is happy and the vision is good the optometrist will complete the report form and send copies to the GP and treatment centre and will discharge the patient.

Clinical governance and patient satisfaction

Levels 1 and 2 of the ‘Quality in Optometry’ (Appendix 3) clinical governance toolkit will be the benchmark used and the contractor 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 distance learning training and accreditation process defined by LOCSU and provided by Cardiff University.

Practitioners wanting to participate in the service will also be required to attend a training session run by the LOC and CCG, primarily to cover the administrative procedures and protocols involved in running the community service.

Practitioners 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.

The benefits[2] of the service are as follows:

For the patient

  • Access to appropriate eye care in local service
  • Less travel time, time off work and related costs (for patients or their carers)
  • More time for questions and answers

For the commissioners

  • 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

  • Simple referral administration
  • Comprehensive reporting for GP about their patient

For the HES and ophthalmologists

  • Fewer inappropriate referrals
  • Improved communication between primary and secondary care
  1. Activity and financial analysis

Assumptions re the existing pathway:

  1. All patients with signs/and or symptoms with cataract are currently referred to secondary care
  2. 65% of cataract referrals proceed to surgery and all patients who have surgery have 2 follow up appointments

Assumptions re the new pathway:

  1. 70% of patients who have primary care referral refinement for cataract will be referred to secondary care
  2. 93% of those referred will proceed to surgery
  3. All patients who have surgery will have one post op check in primary care in the new service

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.

Potential savings per 1,000 referrals / £
Current service
1,000 secondary care initial appointments (£112.00) / 112,000
1,300 secondary care follow ups (£65.00) / 84,500
Total / 196,500
New service
1000 community cataract assessments (£53) plus £10 admin fee / 63,000
700 secondary care initial appointments (£112.00) / 78,400
650 community cataract follow ups (£34.50) / 22,425
Total / 163,825
Saving / 32,675

Cost of new service in primary care is £163,825 therefore anoverall saving of £32,675 per 1000 can be predicted.

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

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

  • Adapt the national pathway to local conditions in discussion with ophthalmologists and commissioners
  • Deliver training and ensure accreditation
  • Develop communication plan and materials for the Hospital Eye Service, patients and the public

7. Risk analysis and mitigations table

Risk / Mitigation
Clinical Risk 1: Post – operative complications and are missed by the optometrist / The service is designed to utilise the core competencies and skills of optometrists. To ensure consistent, high standards among providers, optometrists will undergo a nationally defined training and accreditation process provided by Cardiff University
Financial Risk 1: GPs may continue to refer to the HES if they are not aware of the service, resulting in a reduction in savings compared to those predicted / A communications plan targeted at GPs 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 concerns are addressed.
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 for post-op check. / The pre and post cataract service supports a seamless integration 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 enhanced/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 5) 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 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 optometrist. There is a list of participating optometrists for the patient to choose from.

The criteria for inclusion of patients will be any patient with signs and/or symptoms of cataract in either eye.

Special requirements – equipment

All practices contracted to supply the service will be expected to employ an accredited optometrist and have the following equipment available:

  • Access to the Internet
  • Fundus viewing lens (e.g. Volk)
  • Slit lamp
  • Tonometer
  • Distance test chart (Snellen/LogMar)
  • Near test type
  • Appropriate ophthalmic drugs for pupil dilation

Patient information

A cataract information leaflet will be available and will be handed to patients asappropriate.

[Last reviewed June 2012]

Appendix 2

Performance Monitoring Data Schedule

Case Level data:

  • Patient / GP / CCGidentifiers
  • Patient demographics
  • Appointment(s) date(s) and type(s) – referral refinement or follow up
  • Outcomes

Contract Performance Monitoring Data: For each optometrist, by month / quarter:

  • Referrals by source
  • No. of cataract referral refinement episodes
  • Outcomes
  • No. of onward referrals for surgery
  • No. of patients discharged
  • No. of post – op follow ups
  • Patient satisfaction / complaints / SUIs

Annual joint audit

Appendix 3

Quality in Optometry Core Standards

Many aspects of clinical governance in optometric practice are enshrined in legislation or regulation as well as in the College of Optometrists' Code of Ethics and Guidance on Professional Conduct and in other guidance documents.

Level 1 is GOS contract compliance. This level will be used by NHS England Area Teams for the purposes of checking and monitoring contract compliance. Contractors will be asked to complete and submit a Level 1 report from time to time, together with an action plan for rectifying any non-compliant issues. Practices that flag as outliers on this and other criteria, together with a small random selection of others, may receive compliance visits.

Level 2 is clinical governance specifically designed for optometry community services (previously enhanced services).

There are 3 audits/checklists available. Record keeping is an online version of the spreadsheets available in Level 1 Q13.5. Infection Control and Information Governance summarise relevant elements of Level 1 and present them in a manner appropriate to community services.

Practitioner and non-clinical staff checklists summarise the knowledge that a contractor will require of employees and practitioners as a part of complying with the GOS contract

Community Services

QiO level 2 covers clinical governance with a particular emphasis on community services. The funding for this level of clinical governance is included as part of our proposal.

Appendix 4

Community Optometry Providers – NHS [insert name of CCG]

NHS [insert name of CCG] has [insert number of practices] optical practices currently providing General Ophthalmic Services. [insert name of LOC] LOC has surveyed these practices and has received Expressions of Interest from [insert number] re becoming providers of this service. All of the practitioners involved would undergo the accreditation programme as previously described.

Appendix 5

Management of Community Services

[Insert name of LOC] LOC are now able to provide a full administration service for the management of community services in conjunction with the Local Optical Committee Support Unit.

The fully managed service includes the following:

  • Single point of contact for communications and queries relating to the service.
  • Supply of case data (monthly)
  • Supply of Contract Performance monitoring information with a covering report (quarterly)
  • Exception reports (to be agreed; monthly as necessary)
  • Coordination of any remedial actions necessary
  • Attendance at four Contract Management meetings per year with CCG
  • Report of Annual audit of service

The local community service providers will utilise a web based management solution that can provide all of the administration and data collection within the CCG area. OptoServ collects data, provides activity and outcomes reports and generates electronic referrals and invoices.

Stockport CCG, BucksCCG and Oxfordshire CCGare all currently using the software, created by LOCSU and Webstar Health and savings within these CCGs have already been demonstrated, releasing valuable time and resources within the CCG. Webstar Health also provides bespoke IT management services to disciplines such as Pharmacy. The cost of the IT is included in the overall management cost of £12 per patient.

Key benefits

  • Using the software as part of the community service provides a ‘one stop shop’ that includes administration, data collection and performance reports.
  • It can assist with contract compliance and identify for the CCG any outliers and patient outcomes
  • Quicker, easier administration processes
  • Eliminates manual data processing but can fit in with a practice’s modus operandi
  • Reduces cost and time for the CCG
  • Manages the patient journey
  • Robust Audit available

Appendix 6

National Key Drivers

The national key drivers include:

  • Equity and Excellence: liberating the NHS (2010)
  • Right Care: Increasing Value – Improving Quality (June 2010)
  • NHS 2010-15; from good to great
  • Operating framework for the NHS in England 2010/11
  • Quality Innovation Productivity & Prevention (QIPP) agenda
  • HM Treasury (2010) The Spending Review Framework
  • Creating a patient-led NHS: Delivering the NHS Improvement Plan (March 2005)
  • Commissioning Framework for 2007-8
  • Implement care closer to home; convenient quality care for patients (April 2007)
  • Commissioning Framework for health and well-being (March 2007)
  • Trust, Assurance and Safety – the Regulation of Health Professionals (February 2007)
  • Safeguarding patients ( February 2007)
  • The UK Vision Strategy

LOCSU Cataract Business Case.