NatPaCT works with Primary

NatPaCT works with Primary & Care Trusts

to help them learn & grow together,

as connected and competent organisations

and leaders of radical change

to improve health & services for patients.

Chronic Eye Disease Management in Community

Settings:

First Report of the Eye Care Services Steering Group

Bob Ricketts

Head of Access Policy Development & Capacity Planning

Department of Health

David Hewlett

Head of Dental and Optical Commissioning Group

Rosie Winterton MP

Minister of StateDepartment of Health

Blindness: Vision 2020 - The GlobalInitiative for the Elimination of Avoidable Blindness•disease prevention and control•training of personnel•strengthening of the existing eye care infrastructure•use of appropriate and affordable technology•mobilisation of resources

NHS PLANCore Principles 3,4,8• The NHS will shape its services around

the needs and preferences of individual patients, their families and their carers

• The NHS will respond to different needs of different populations

• The NHS will work together with others to ensure a seamless service for patients

“Fair for alland personal

to you”

John Reid16 July 2003

Eye Care Services Steering Group

• Set up by Ministers in December 2002

• Worked on GMS, dentistry and pharmacy and ophthalmics now moving forward

• Growing need for eyecare services and major quality of life issues

Source ONSSource ONS

Demographics

4.1 3.8

7.9

5.5 5.0

10.5

02468

1012

65 to 74 Over 75s Over 65s

Po

pu

lati

on

Mil

ion

s

Year 2002

Year 2020

Source ONS

Population Increase65 - 74 34%Over 75s 33%

Over 65s 33%

• Half of over 65s have impaired vision in one or both eyes

• Increase in elderly

Four Pathways

• Cataract• Glaucoma• Age Related Macular Degeneration

(ARMD)• Low Vision Services• Diabetic retinopathy being tackled

separately as part of Diabetes NSF

Design Principles

• Make best use of available resources• Have fewer steps for the user• Make more effective use of professional

resource• Show a high standard of clinical care with

good outcomes• Improve access and deliver greater patient

choice• Evidence based

Conclusions

• Primary care ophthalmic services need to be developed to meet demographic demand

• Partnerships with primary & secondary care, patients and carers essential

• Integrated IT needed but not prerequisite• Voluntary agency and social services

involvement important

Care Pathways Designed to Achieve:

• Integrated eye care services• Better use of skills in primary care• Increased amount of care for all in

accessible primary care settings• Increased role for professional groups in

primary care

Recommendations • Cataract pathway to be implemented when

waiting times reduced to 3 months • £73million additional funding to achieve 3 month

cataract waits by December 2004• Glaucoma pathway to be piloted initially• ARMD and Low Vision to be taken forward

within existing funds• £4million for innovative projects and pilots• GOS Regulations to be amended to allow direct

referral by optometrists

Why are we here?

• Share our report with you• Consider, if you agree with us,

how we take it forward together

Elizabeth Frost

DirectorAssociation of Optometrists

&Chair, Cataract Working Group

Background

• Mainly elderly population• Many misconceptions about cataract

surgery• Changes in HES• Action on Cataracts

Current Cataract Pathway• Patient reports sight problem to GP• Patient goes to optometrist/OMP for sight test and

optometrist/OMP refers patient to GP• Patient goes to GP, referred to HES• Patient seen at HES, cataract confirmed, decision to

operate, and put on waiting list• Patient attends HES for pre-op assessment• Patient attends HES for day case surgery• Patient attends HES for 24 hr check• Patient attends HES for 6 week check, 2nd eye

discussed• Patient attends optometrist/OMP for sight test and new

specs.

Proposed Cataract Pathway

1. Patient attends optometrist/OMP for sight test, cataract diagnosed and discussed, general risks & benefits of surgery explained, current medication listed, patient information given, and appointment made for HES, with choice of provider (copy of referral to GP for info)

2. Patient attends HES to see ophthalmologist and for pre-op assessment

3. Patient attends HES for day case surgery4. Patient attends HES/optometrist/OMP for 24/48 hr check OR is

phoned by cataract nurse to check progress (agreed locally)5. Patient attends optometrist/OMP for final check and sight test, 2nd

eye discussed.

Proposed Cataract Pathway

1. Patient attends optometrist•Sight test, cataract diagnosed and discussed

•General risks and benefits of surgery discussed•Patient wishes to proceed, information given etc

•Patient offered choice of hospital and appointment agreed

2. Patient attends HES•Outpatient appointment with

ophthalmologist*•pre-assessment (with nurse?)

•Date for surgery arranged/agreed

(* details of medication etc received from optometrist, GP or

patient as per local protocols )

3. Patient attends HES•Day case surgery undertaken

4. Patient attends HESor Optometrist

•Final check•Sight test

•Discharged or2nd eye discussed andappointment arranged

Start Finish

Who should be referred?

• Not a ‘fast track’ service• Suitable for those who –

– have a cataract that is interfering with their daily living

– have been given basic information about cataract surgery, and risks / benefits

– want to have surgery

Evidence of Success

• Several services developed and audited• 90%+ referrals proceeding to surgery• cf 80% for traditional referrals• Reduced time to surgery from 12 to 3 months• Surgical outcomes meet RCO guidelines• Reduced DNA rates• Greater nurse involvement• High patient satisfaction

Constraints to Success

• Not funded centrally through GOS budget• To be funded by existing PCT budgets• Investment needed in equipment and

staffing• Needs mutual inter-professional trust and

teamwork• Lack of IT booking links will hamper

Key Recommendations for local action

• Reduce number of steps in pathway• Eliminate duplication• Improve IT links – optometrist/OMP/HES• Develop protocols for discharge from HES

to optometrist/OMP with audit feedback• Agree funding

Stephen Vernon

Royal College of Ophthalmologists &

Chair, Glaucoma Working Group

Chronic Glaucoma gives tunnel vision

10 years

Testing for glaucoma

UK population by age 2001

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

0-4 5.0-9.0 10.0-14.0

15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75=79 80-84 85-89 90+

Age range

no

in

mil

lio

ns

UK population by age - 2001

Age range

4200

2

4

6

8

10

12

ObservedExpected

Age group

Per

cen

tag

e

<60 60-69 70-79 80+

BMES PREVALENCE OF POAG

<60 60-69 70-79 >80Age Group

Nos of glaucoma in UK by age

0

10

20

30

40

50

60

70

35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75=79 80-84 85-89 90+

Age

No

in

th

ou

san

ds

Estimated numbers of glaucomas in UK by age (1000s)

Age

Current Glaucoma Pathway(Hospital Based Care)

1. Single screening opportunity by community optometrists with no standardised protocols

2. Diagnosis and continued care for life of all glaucoma (and many suspects) within Hospital Eye Service by ophthalmologists

Proposed Pathway (Community Based Care)

1. Community optometrists work to nationally agreed screening protocols which permit refinement of tests prior to referral

2. Glaucoma suspects and stable glaucoma patients managed in the community by COs and OMPs with interaction of community and HES teams where appropriate

The 5 Care PathwaysThe 5 Care PathwaysCare Pathway 1Care Pathway 1

Ocular Hypertension Ocular Hypertension

Care Pathway 2Care Pathway 2

Glaucoma without other eye disease Glaucoma without other eye disease

Care Pathway 3 Care Pathway 3

Glaucoma suspect on discs and/or fields Glaucoma suspect on discs and/or fields

Care Pathway 4Care Pathway 4

Glaucoma in presence of other significant eye disease Glaucoma in presence of other significant eye disease

Care Pathway 5 Care Pathway 5

Refinement of community optometric referralsRefinement of community optometric referrals

Proposed Glaucoma Pathway

1. Patient attends community optometrist (CO)•Sight test, IOP over 21 (applanation tonometry) and/or

visual field defect and/or excavated discs•Patient/optometrist makes appointment with optometrist

with special interest in glaucoma (OSI) or OMP

2. Patient attends OSI or OMP•Full history and assessment carried out according

to protocol•Decision taken as to whether patient has ocular

hypertension (OSI/OMP reviews) or can be discharged (return to CO) or has glaucoma (treat

or refer to HES)•Patient advised, given information etc and further

appropriate appointments made if needed

3. OSI/OMP relays data to HES•HES reviews data, advises OSI/OMP

regarding management and sets up review at HES if needed

4. OSI/OMP manages patient in community setting•Regular reviews set in

place•OSI/OMP relay data to

hospital if significant progression for HES

review if needed

Start

Evidence Base

• Only 33% of suspect glaucoma referrals found to have glaucoma by HES

• Optometrists with additional training can assist in glaucoma management freeing up ophthalmologist and hospital time

• Refinement of referrals for suspect glaucoma by specially trained optometrists reduces HES referrals

Constraints to Achievement

• Funding issues - increased revenue costs • Training requirements • Legal issues for prescribing rights• Information Technology issues• Communication• Record keeping• Audit

Key Recommendations for Local Action

• Community optometrists conform to College guidelines for referral of glaucoma suspects

• HES services utilise optometrists to assist in glaucoma care within the HES

• Community refinement of optometric referrals established utilising OMPs and optometrists with a special interest in glaucoma

• Community care of “straightforward” glaucoma cases by OMPs and optometrists with a special interest in glaucoma

Frank MunroPresident

College of Optometrists&

Chair, ARMD Working Group

OBJECTIVESOBJECTIVES• Map out the current care

pathway

• Identify inhibitors & barriers to change

• Identify areas for improvement

• Develop proposals for a new integrated care pathway for patients with ARMD

WHAT IS AGE RELATED MACULAR WHAT IS AGE RELATED MACULAR DEGENERATION(ARMD)?DEGENERATION(ARMD)?

• Acquired condition - > over 60 years

• ‘Wet’ & ‘Dry’ forms• Affects central vision• Almost 1 million in England• Commonest cause of

irremediable visual loss• Accounts for 14% blind &

partially sighted registrations( 50% for those > 65yrs)

• Limited credible treatment options

ASSOCIATION BETWEEN ASSOCIATION BETWEEN VISUAL IMPAIRMENT &…..VISUAL IMPAIRMENT &…..

• Increased mortality• Increased morbidity / falls / fractures• Increased road accidents• Increased anxiety & depression• Poorer self care & independence• Greater need for community & institutional

resources• Social isolation - quality of life• Loss of income

DEMOGRAPHICSDEMOGRAPHICS

AMDAMD•1998 approximately 8.3 1998 approximately 8.3

on people over the age on people over the age of 65 in England of 65 in England and Walesand Wales

●4.3 million have impaired 4.3 million have impaired visionvision●AMD is the leading AMD is the leading cause in over 65scause in over 65s

By 2020By 2020●A 25% increase in the A 25% increase in the over 65 population is over 65 population is expectedexpected●Incidence of ARMDIncidence of ARMD expected to rise by 31% expected to rise by 31%

AMD: A Growing ProblemAMD: A Growing Problem• Burden recognised by government

– NSF for Older People• Vision impairment is

an intrinsic risk factor for falls

– NICE: Recent guidance on PDT for wet-AMD

• NICE to review new treatments in 2005

• In meeting future demand, service will have to respond to increasing patient numbers and delivering new therapies

Current ServicesCurrent Services• There are many good

points about today’s services:– Access to angiography in

most (if not all) eye departments

– Access to Argon laser in all eye departments– Great awareness of AMD in general optical

services– Prompt access for suspected wet AMD in most

secondary care sites– In some centres access to LVA, LV1, social

services advice is almost one stop

Current ARMD PathwayCurrent ARMD Pathway

• Patient reports visual problem• GP refers patient to HES OR• Patient is referred to an optometrist• ARMD is diagnosed• Patient is referred to HES via GP• Fluorescein angiography carried out• Any credible treatment option considered• Patient managed by HES or by Low Vision Service• Patient registered• Referred for Social Service &

Rehabilitation support

Problems with Current ServicesProblems with Current Services

Can be a lack of collaboration / communication between healthcare and

social service providers

Lack of timely diagnosis and ease of access to treatments / social services

for patients with AMD

What do patients What do patients want from future services?want from future services?

• Rapid and precise diagnosis in primary care • Access to medical retina specialists advice• Rapid access to treatment when appropriate• Access to LVA services to make best use of

remaining sight• Understand risk factors• Improved communication

between:– Clinicians and patients– Different service providers

• Further research

Need to Manage AMD DifferentlyNeed to Manage AMD Differently

Improve collaboration / communication between healthcare and social

service providers

Ensure timely diagnosis and ease of access to treatments / social services

for patients with AMD

The ‘NEW’ AMD PathwayThe ‘NEW’ AMD Pathway

PATIENT PRESENTS WITH VISUAL PROBLEM AND IS EXAMINED BY COMMUNITY PATIENT PRESENTS WITH VISUAL PROBLEM AND IS EXAMINED BY COMMUNITY OPTOMETRIST IN TRIAGE CAPACITY – DIFFERENTIAL DIAGNOSISOPTOMETRIST IN TRIAGE CAPACITY – DIFFERENTIAL DIAGNOSIS

SELFSELFREFERRALREFERRAL

REFERRED BY REFERRED BY ANOTHER CLINICIAN OR ANOTHER CLINICIAN OR

CARERCARER

OTHER SOURCEOTHER SOURCE

NOT NOT ARMDARMD APPROPRIATE APPROPRIATE

CARE ASCARE ASINDICATEDINDICATED

SYMPTOMS SUGGESTIVE OF ARMDSYMPTOMS SUGGESTIVE OF ARMD

‘‘DRY’ (NON-NEOVASCULAR)DRY’ (NON-NEOVASCULAR)ARMDARMD‘‘WET’ (NEOVASCULAR) OR WET’ (NEOVASCULAR) OR

SUSPECTED ‘WET’SUSPECTED ‘WET’ARMDARMD

DIRECT REFERRAL TO HES FOR DIRECT REFERRAL TO HES FOR FLUORESCEIN AGIOGRAPHY FLUORESCEIN AGIOGRAPHY

ANDANDFURTHER INVESTIGATIONFURTHER INVESTIGATION

TREATABLETREATABLE

UNTREATABLEUNTREATABLE

ACCESS TO TREATMENTACCESS TO TREATMENT

OPTICAL / OPHTHALMICOPTICAL / OPHTHALMIC

LOW VISION SERVICESLOW VISION SERVICES

COUNSELLINGCOUNSELLING

SOCIAL SERVICE SUPPORTSOCIAL SERVICE SUPPORT

REHABILITATIONREHABILITATION

BD8/LV1 AS REQUIREDBD8/LV1 AS REQUIRED

Summary of EvidenceSummary of Evidence• 2/3rds with vision impairment are over 65 years of age• ARMD commonest cause of irremediable serious visual

loss in people over 65 years of age• Macular degeneration - 14% of new partial sight & blind

registrations for working population (aged 16-64)• Exponential increase in ARMD over the age of 75• Demographic shifts in population - increase of

approximately 30% over next 20 years• Reductions in contrast sensitivity, depth perception and

peripheral vision linked with risk of falls or hip fracture• Visual impairment important risk factor for hip fracture

and falls

Inhibitors and BarriersInhibitors and Barriers

• Adequate Funding – fees, IT etc• Human resources / recruitment• Patient / Practitioner

Communication• Competitive behaviour• Lack of Inter Professional

Collaboration• Lack of patient understanding• Lack of trust• Poor understanding / recognition

of the role of other professionals

Key recommendations for local Key recommendations for local actionaction

• Community optometrists encouraged to comply with College of Optometrists guidelines when examining older people

• Direct referral to the HES by optometrists should be introduced

• Care networks involving all carers established to ensure comprehensive care for all patients within an integrated structure

• Best possible patient care to be the clear focus of all involved

Elizabeth Bates

Co- Director, Greater Manchester Children’s Network

& ChairLow Vision Services Working Group

Aim of Pathway

“A growing number of the most vulnerable people in this country experience a quality of life that is significantly, but unnecessarily, diminished for the want of basic, relatively inexpensive health care”

(RNIB 1999)

Key Issues

• Vast majority of people with low vision are over 70

• Most people with low vision retain some sight • Sight can be maximised by:

– prompt advice and counselling– early assessment– provision of appropriate low vision aids (LVAs) and

training in their use

• Effective low vision services can reduce admissions to residential care

Current Low Vision Pathway

• Fragmented• Wide variation re access & quality• Referral from optometrist (often via GP) to HES• Uni-disciplinary• Lack of information, signposting & awareness• Long waiting times• Initiation of LV services ONLY after

ophthalmological assessment

Proposed Low Vision Pathway(1)

• Emphasis on low vision services not provision of low vision aids

• Led by Primary or Social Care • Partnership Approach• Providing Services which promote:

– Awareness– Timeliness– Accessible

Proposed Low Vision Pathway(2)

• Establishment of a key worker model • Registration not a pre-requisite• Medical assessment not a pre-requisite • Services enable re-access and re-

assessment• Better utilisation of relevant health & social

care professionals

4. Service enables re-access

Proposed Low Vision Pathway

1. Patient referred to Low Vision Service (LVS)

•Referral may be from secondary care, GP, social worker, rehabilitation officer, community nurse, OT etc or may

be self referral•Patient may have an LVI, RVI or CVI

•All patients are contacted by LVS within 10 working days

2. Patient attends LVS•Service is seamless across health, social care and the voluntary sector

•A full sight test forms part of assessment•Patient is given information on eye condition, entitlements etc as well as local services

• Counselling and advice on employment or education is available•Spectacles, LV aids, advice (esp. lighting, contrast and size) and home adaptations are

discussed and made available as appropriate•Referral to other areas of health and social care as needed, including certification

3. Patient has follow up visits as needed

•Visits may take place in the patient’s home or elsewhere•Visit will be by appropriate

member of the LV team

Start

RecommendationsNational Action• Develop national eligibility

criteria & core standards• Review existing funding

streams• Understand workforce

implications• Develop generic training

programme • Audit existing services

Local Action• Develop local partnership

arrangements with designated lead officer/organisation

• Integrate LV assessment into the Single Assessment process for older people

• Move to provision of LV aids via a “loans” service

• Consider opportunities offered under the new GMS contract for LV screening

Benefits, Next Steps, Commissioning Options

Benefits for patients

Better care:

access

speed

convenience

Benefits for the NHS

• shorter waiting times

• better use of skills

• better value for money

Review of General Ophthalmic Services

• Department reviewing General Ophthalmic Services

• Currently a central budget for limited service - need to consider if that supports modernisation proposals

Next Steps

• Local commissioning and planning across sectors to deliver integrated service

• Pathways a resource to inform planning and provide ideas for development

• Flexibilities in current system allow for progress now

Commissioning Options

• PCTs can already purchase services in primary or secondary care

• PCTs can joint fund with social services to deliver integrated service

Delivering Effective Patient Choice in Cataract Surgery

Ann WagnerProgramme Director

West Yorkshire Patient Choice

Delivering Effective Patient Choice in Cataract Surgery

• Choice and wider system reform context• West Yorkshire Patient Choice Cataract

Pilot• Opportunities and Challenges

What is Choice all about?• Dept of Health policy to deliver more choice and certainty

to patients• Starting with choice of elective care, choice will

eventually be rolled out to all service areas • Starting with choice of when and where, choice will be

expanded to include choice of what and who • Needs to be seen in context of wider system reform

agenda • linked to financial flows – payment by results, agenda for

change, booking, e booking and NPFIT and plurality and diversity agenda.

• A key enabler for choice is booking and e booking

Choice Targets

• From end April 2004, patients waiting over 6 months to be offered choice of at least one alternative provider

• From January 2005, all cataract patients to be offered a choice of at least two providers at point of referral

• From April 2005, heart surgery patients to be offered choice of hospital at point cardiologist refers them to a cardiothoracic surgeon

• From December 2005, all patients requiring elective care to be offered choice at point of referral of 4 or 5 alternatives

West Yorkshire Patient Choice Cataract Pilot

Community of Interest:• 15 PCTs• 5 Acute Trusts• 4 LOCs• Host PCT with DTC capacity and capability• Clinical Engagement• Supportive SHA• Financial support of DoH


Aim: to improve the patient experience by:• Giving patients much greater influence over

treatment• Reduce waiting times• Increase activity• Improve service delivery• Challenge ways of working

Focus: day case cataract surgery at Westwood Park DTC


Choice Objectives:• Targeting long waiters• Choice in secondary care• Choice in primary careTo support West Yorkshire Health Community in delivering choice for all


Developing clinical and patient pathways• Process mapped existing pathways and practice• Benchmarked against best and recommended

practice • Considered options and where to put choice for

greatest benefit• Agreed way forward including supporting

common information, referral forms, Optom fees and clinical audit

Optometrist Outpatient waiting list

Where do we offer Choice and Booking?

Booking

Inpatient/ Daycase

Treatment

Assessment

3 mth max 3 mth max

ChoicePost Op

Assessment

OptometristSight Check

• Who offers Choice?

• Who makes the booking?


Opportunities:• Improve the patient experience• Strengthen community of interest• Explore single site capacity expansion• Test out national tariff• Develop more effective pathway• Take a proactive, patient centred approach to

evaluation and peer review• Pilot choice


Challenges:• Corporate buy in• Optometrists fees• Putting choice into the pathway• Loss of control• Conflicting policies/ competing priorities• Referral thresholds and discharge protocols• Data and patient tracking• Transport• Not reinventing the wheel

“And should there be a sudden loss of consciousness during this meeting oxygen masks will drop

from the ceiling”

Contact Details

Ann WagnerProgramme DirectorWest Yorkshire Patient Choice

Tel: 07970 770708, 01274 322537E mail : [email protected]

NatPaCT works with Primary

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