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Betsi Cadwaladr Health Board ‘s Ophthalmic Health Plan

2014-2018

Version 1.3 produced 5/6/2014

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Overview

The National Eye Health Care Delivery Plan was issued in September 2013 setting out the strategic direction for eye services in Wales with a range of key deliverables for Health Boards. The National Eye Health Care Delivery Plan is structured around 3 key themes of action, these include:

� Raising Awareness of eye health and the need for regular sight tests � Early detection of poor eye health and sight problems – targeted for people at risk � Providing access to high quality, integrated services and support

� Primary and community services � Specialist Hospital Services � Supporting people with sight/dual sensory impairment.

This plan has been developed in response to the national standards as set out in the National Eye Care Delivery Plan and sets out the Health Board’s key actions and timeframe for delivery to ensure that we meet national requirements.

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KEY THEME 1: RAISING AWARENESS OF EYE HEALTH AND TH E NEED FOR REGULAR SIGHT TESTS

The Health Board recognises the importance of Health Promotion and is committed to providing the residents of North Wales with information on eye health care services in North Wales.

KEY ACTIONS MILESTONES FOR DELIVERY MEASURES OF SUCCESS

LEAD OFFICERS

Ensure eye health statistics and demographics are routinely included in NHS Needs Assessment and reports of directors of Public Health for each Health Board.

From April 2014 the North Wales Public Health team will ensure as a team that:

• eye health statistics and demographics are included in the North Wales profile (the global needs profile for North Wales) where routine data is available; and that

• the team will reference eye health statistics in the Director of Public Health Annual Reports where relevant.

• The Eye Care Pathway Group will review the demographic information produced to assess whether the services in North Wales are appropriate for the needs of the population.

Reports containing eye health statistics Ophthalmology service developments business cases based on population demographics and prevalence of conditions in North Wales

Associate Director of Public Health North Wales /Eye Care Pathway Group

Work with the Regional Optometric Advisors in Public

The Health Board will develop an eye health promotion strategy by September

Leaflets available at

Regional Optometric

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Health Wales, DRSSW , Optometrists, Dispensing Opticians, Orthoptists, Pharmacists, GPs and the Third Sector to promote the importance of eye health care.

2014 on information to be circulated to its staff and the public at outpatient departments, Optometric practices, and GP practices that will include:

• Eye Safety - Prevention of Eye Injuries in the workplace and at home; a campaign for adults and children.

• Healthy Lifestyle campaigns to include impact on eye health – Smoking cessation campaigns to include informing smokers about the increased risk of AMD and cataracts. Regular Exercise campaigns to inform the public about the impact on eye health of high blood pressure and diabetes. Alcohol consumption to inform the public of the increased risk of early AMD with heavy alcohol consumption. Diet to inform the public of the risk of AMD and poor eye health as a result of diabetes with poor diet.

• Contact lens safety – preventing eye infections;

public locations across North Wales Reduction in Eye Injuries attending Eye Casualty Improvement in Smoking cessation uptake

Advisor/ Optometry Liaison Group/ North Wales lead Orthoptist

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• Protecting eyes from the sun – the risk of irreversible damage that can lead to cataracts or even blindness.

This strategy will ensure the Health Board has an annual communication programme that incorporates eye health from 2015/16 onwards. It will align key messages with relevant National awareness weeks such as:

• Diabetes week • Eye Health Week • Glaucoma Week • Macular society awareness week

Opportunities for earlier implementation will be considered during the strategy development phase.

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KEY THEME 2: EARLY DETECTION OF POOR EYE HEALTH AND SIGHT PROBLEMS – TARGETED FOR PEOPLE AT RISK

The Health Board recognises the value of screening programmes to ensure early detection of eye health and sight problems and is committed to improving and promoting these screening programmes to the residents of North Wales.

KEY ACTIONS MILESTONES FOR DELIVERY MEASURES OF SUCCESS

LEAD OFFICERS

Work with the orthoptic lead for children’s vision screening to improve the quality of children’s screening- including reviewing training, equipment and monitoring in light of national standards.

• Continue to audit services against the NSC guidelines whilst WG standards are in development. The outcome of the audits to be shared with the Eye Care Pathway Group at the meeting scheduled in August 2014

• BCU representation on the Welsh Government’s Children’s Vision Advisory committee. This group is considering national standards for training, equipment and the care pathway. March 2014 - Ongoing

• BCU representation on the School Pupil Eye Care Services Task and Finish group. This Group is developing an agreed pathway for regular eye testing at Special

Increased uptake in training Adequate equipment provision

North Wales Head Orthoptist/ Children’s vision advisory committee

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Schools. BCU Orthoptist will work with Optometry services to ensure implementation.

• A baseline assessment of current training and equipment in BCU to be undertaken in advance of receiving the national standards. September 2014

• North Wales Vision Impairment Benchmarking Group to provide comparative information on school vision screening provision across North Wales. December 2014

• BCU to assess services against the standards and pathways agreed at the Children’s advisory committee and address areas of non-compliance. On receipt of agreed National Standards

Work with the Regional Optometric Advisors in PHW, DRSSW, Optometrists, Pharmacists, GPs and the Third Sector to promote EHEW and DRSSW, especially to high risk

• The Health Board will develop a communication strategy by September 2014 for information on Eye Health Examinations and Diabetic retinopathy screening programmes to be circulated to its staff and the public at outpatient

Increased uptake of DRSSW screening services Increased

Eye Care Pathway Group/ Regional Optometric Advisor/ GPs/Optometry Liaison Group

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groups. departments, Optometric practices, and GP practices. In particular:

• Review to be undertaken with GP practices to identify the action taken by practices where patients failed to attend DRSSW appointments

• Optometric practice campaigns alerting patients to EHEW examinations.

uptake in EHEW eye examinations

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KEY THEME 3: PROVIDING ACCESS TO HIGH QUALITY, INTE GRATED SERVICES AND SUPPORT

KEY ACTIONS MILESTONES FOR DELIVERY MEASURES OF SUCCESS

LEAD OFFICERS

Project Infrastructure Arrangements Work with Eye Care Liaison Groups to ensure services are planned, monitored and reviewed with clinicians from primary and secondary care

The Health Board’s Eye Care Pathway Group is responsible for:

• Ensuring patients receive services promptly, from an appropriate provider in a location as close to home as possible

• Developing models of care across the Health Board ensuring that services are appropriately aligned and Optometric, Orthoptic, Nursing and Medical resources are used effectively and efficiently in the provision of patient centred care.

• Providing a comprehensive and equitable Eye Care service for the people of North Wales.

The Health Board’s Optometry Liaison Group ensures effective communication

Primary Care and Secondary care clinicians on Eye Care Pathway Group BCU Health Board Ophthalmic Health Plan is place Regular review of BCU Health Board’s Ophthalmic Health Plan

Eye Care pathway Group/ Optometry Liaison Group

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between the Health Board and Optometric services. It considers all aspects of optometry and related matters that affect access to services for the population of North Wales and Optometrists practising in North Wales.

Review and Develop workforce plans to deliver new ways of working

• Complete a staffing levels review of ophthalmic services across North Wales by September 2014.

• Ensure full implementation of good practice FOO pathways as models for service delivery by December 2014.

• Develop further alternative models of working, i.e increasing nurse led, virtual clinic, optometric service and orthoptic services December 2014 .

• Ensure Ophthalmic service models are aligned to the wider BCU Strategic Service Plans.

• Produce workforce plan to ensure service sustainability within affordable financial envelope March 2015 .

Workforce Plan in place for Ophthalmology. Annual review of workforce plan.

Surgical and Dental workforce and OD Group/Eye Care Pathway Group

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Develop and systemise the use of patient outcomes and experience measures of primary care, secondary care and social services

• DSU audits to be undertaken for AMD and Glaucoma and will include the collection of patient satisfaction survey.

• 2014/15 BCU will work with patient experience leads to develop a patient feedback programme for other services, including Cataract, Diabetic Retinopathy, unscheduled care, paediatric services.

• Patient outcome measures being developed nationally for implementation

Report on patient experiences submitted to Surgical and Dental CPG annually. Improvement in patient satisfaction

Nia Jones/DSU/ Helen Juckes- Hughes/ Neil Pearson

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KEY ACTIONS MILESTONES FOR DELIVERY MEASURES OF SUCCESS

LEAD OFFICERS

Primary and Community Services Ensure Optometrists, Dispensing Opticians, Pharmacists, Practice Nurses and GPs are aware of primary eye care referral pathways.

• WECS triage scheme to commence across North Wales where all referrals into Ophthalmology are triaged by WECS accredited optometrists. June 2014.

• This will ensure patients are directed to the appropriate eye care services in both primary and secondary care

• Updated list of WECS accredited optometric Practices to be circulated to GPs, Dispensing opticians and Pharmacies June 2014

• Updated list of optometric Practices providing unscheduled care service provision to be circulated to GPs, Dispensing opticians and Pharmacies June 2014

Increased WECS activity. Reduction in the number of referrals to secondary care

Assistant Director Planned Care Ops Improvement & Delivery Support/Lead Manager Operational Improvement/ Optometrist Liaison Group

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• The Health Board will communicate all new ophthalmic service developments to GPs and Optometrists

Work with optometrists, ophthalmologists, orthoptists and GPs to audit referrals from primary care and secondary care (unscheduled care and outpatients)

• All outpatient referrals will be reviewed as part of the WECS triage scheme due to commence across North Wales – May/June 2014

• Feedback will be provided to the referrer on the quality of the referral and the re-direction of the referral where appropriate.

• Unscheduled care referrals access the Eye Care Departments via a triage system. Need to ensure that this is consistently applied across North Wales.

• Establish mechanism for feedback to be provided to referrers where patients referred to Eye Casualty could have been seen in the primary care setting.

• Audit to be undertaken on the proportion of onward referral from Optometrist unscheduled care services to Secondary care.

• Increase in WECS activity

• Reduce number of referrals returned to primary care as inappropriate for secondary care.

• Assistant Director Planned Care Ops Improvement & Delivery Support /Optometrist Liaison Group/Lead Manager Operational Improvement

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KEY ACTIONS MILESTONES FOR DELIVERY MEASURES OF SUCCESS

LEAD OFFICERS

Specialist Hospital Services Developing Eye Care services in North Wales Collect, report and monitor capacity and demand for eye care services.

- Capacity Planning models are updated annually to inform discussions on the delivery of referral to treatment targets.

- Activity and waiting list profiles developed to monitor progress towards delivery of targets

- Demand information is available on a monthly basis.

- At 31st March 2014 patients were waiting 52 weeks for RTT. Capacity planning to: meet 36 weeks by March 2015 meet 26 weeks by March 2016

Service delivery meeting planned profiles.

Acting Director Improvement and Business Support/Lead Manager Operational Delivery

Work with ophthalmologists to ensure all referrals to secondary care receive a response

During 2014/15 WECS accredited Optometrists participated in the review and clinical prioritization of both New and Review patients across the Health Board. This prioritization and review work is being taken forward as a pilot with ABMU Health Board as part of the Health Minister’s commitment to develop clinically led intelligent targets.

Patients booked according to clinical priority. No patients waiting over 36 weeks at 31st March 2015

Assistant Director Planned Care Ops Improvement & Delivery Support / David Saunders/Syed Amjad/Eoin Guerin/Lead Manager

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This work will continue during 2014 to ensure that those patients who need to be treated in secondary care who have the greatest clinical need are seen in a timely manner. This workstream will need to address the fact that there is currently insufficient capacity to meet the demand. This workstream will need to ensure that all patients are provided with a realistic expectation of the timeframe within which they will be seen. Milestones to be delivered are as follows:

• Project board established- roles and responsibilities agreed- by end of April

• Data flow established for data collection-

• Validation of outpatient follow-up list-

o first stage administration validation

Operational Improvement

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o Clinical validation • Clinical prioritisation of follow-up-

based on longest waiters over their original follow-up date. To be initialised through review of electronic clinical letter/case note review.

• Long waits identified by consultant with list of review by date order- plan review last clinic letter during non clinical sessions and prioritise P1-P3

• Aim to book P1 patients by target date for review –progress on ability to book by target date will form one of the measures of success.

• It was agreed that more discussion and agreement has to be undertaken on the balance of priority of a P2 long waiter as compared to a P1 short waiter. It was agreed that this would form part of the review when the information flow shows delivery delays by priority and length of delay.

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Pilot to be completed by the end of August 2014 .

Focus on Ophthalmology Pathways

Work with local stakeholder Groups (including optometrist, ophthalmologists, orthoptists and GPs) and NHS Wales Delivery and Support Unit (DSU) to review patient pathways to ensure they remain fit for local purpose whilst delivering national standards

• BCU representatives have 90 day reviews with DSU to discuss progress towards implementation of the Focus on Ophthalmology pathways.

• DSU audits for Glaucoma and AMD will be undertaken during 2014/15 to assess compliance against nation standards

• Pathway implementation action plans developed to address areas where BCU are non compliant to ensure delivery by December 2014

90 day review reports to be submitted to Eye Care Pathway Group DSU sign off of Glaucoma, AMD and Unscheduled care pathway

Nia Jones/DSU/Eye Care Pathway Group

Glaucoma Establish ODTCs for Glaucoma

• ODTCs established in Caernarfon, Deeside and Colwyn Bay – April 2014

• All sessions operational by July 2014

• Competency training to be undertaken to ensure ODTC staff can receive new patients for assessment. July-November 2014

Increased ophthalmology activity Reduction in the number of patients beyond their due date for follow ups

Divya Mathews/ Patrick Kinahan/ Kamal Sahni

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• New patients from November 2014

Reduction in the number of new patients waiting over 36 weeks.

Work with pharmacists to review adherence with Glaucoma medication including in a care home setting

With regards to adherence with eye medication Community pharmacies other than providing dispensed medications to care homes no longer routinely visit them to advise on medication as this enhanced service was de-commissioned by the LHB several years ago.

• The Health Board will review the previously decommissioned service to see whether it is appropriate to re-commission this service.

• The Health Board will work with the local International Glaucoma Association rep to understand how compliance can be monitored appropriately.

Training sessions arranged in care homes Leaflets educating on proper application of eye drops distribute in care homes

Community Pharmacy Wales Regional Director North Wales/ International Glaucoma Association

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Age-related Macular Degeneration

In order to deliver the AMD pathway for BCU there are still the following actions to be undertaken:

• There is no treatment room in Ysbyty Gwynedd outpatient department. Funding has been secured for Estate development and it is on the Estates Departments work programme for 2014/15.

• BCU Health Board have revisited the proposal of a one site model and are still of the opinion that it is not the favoured approach in terms of maximising efficiency of clinic capacity. It is therefore modelling a service for 1st injection within 2 weeks. December 2014

All patients having first treatment in 2 weeks All patients having review appointments in 4 weeks whilst on treatment programme

Lead Manager Operational Improvement/Lead Manager Operational Delivery/John Mathews

Ensure there is a transparent process for considering and implementing National Institute for Health and Clinical Excellence (NICE) guidance that involves Ophthalmologists and patients.

Applications for NICE approved medication are developed by ophthalmologists and presented to the Surgical CPG for approval in the first instance. There is Ophthalmic representation on the CPG Board. Once approval is acquired by the CPG Board it is presented to the Drugs and Therapeutics Group (DGT) which has

NICE approved drugs taken to DTG within 3 months of publication Ophthalmologist on the DTG

Surgical and Dental CPG and Drugs and Therapeutic Group

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patient representatives and Ophthalmic representation

• Consider whether further ophthalmic representation is required. July 2014

• Consider whether patient involvement needs to be considered as part of the CPG approval process July 2014

Unscheduled Care

• List of WECS unscheduled care services to be circulated to GPs, OOH services, and A&E Departments. – July 2014

• Audit to be undertaken by BCU to ensure triage service is operating consistently across the three sites – August 2014

• Eye casualty clinic activity to be reviewed to ensure that it is being used appropriately for unscheduled care only and that there is sufficient capacity on all three sites.

• Public campaign to raise public awareness of primary care emergency eye care services especially WECS. Following the unscheduled care audit undertaken

Increase of WECS activity for unscheduled care Reduction in Eye Casualty attendances

Optometry Liaison Group

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by DSU it was demonstrated nationally that there remained a lack of public awareness of the services available. BCU will look at feasibility of a postal public awareness campaign for WECS – December 2014

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KEY ACTIONS MILESTONES FOR DELIVERY MEASURES

OF SUCCESS LEAD OFFICERS

Supporting people with sight/dual sensory impairme nt Ensure effective referrals to social services, LVSW and third sector from the hospital eye service where the individual would benefit from an assessment by a rehabilitation officer and where appropriate a rehabilitation programme.

• North Wales ECLO services established on all three sites currently. The post in Ysbyty Gwynedd is currently funded by RNIB until February 2015. BCU will need to secure continued funding for ECLO services to continue beyond this date. September 2014

• Activity of ECLO funded by RNIB is reported quarterly, which includes information on rehabilitation team referrals. This information is to be collected for all 3 sites from May 2014.

• Review information collated by the North Wales Vision Impairment Benchmarking Group which includes social services and third sector data. September 2014

• Improve glaucoma patient uptake in visiting their local ECLO. A trigger point identified to remind patients of ECLO services is the

Increase in referrals to rehabilitation programme

Lead Manager Operational Improvement/ RNIB ECLO services co-ordinator

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point at which the patient stops driving. March 2015

Ensure effective referrals to LVSW and third sector from the hospital eye service

• North Wales ECLO services established on all three sites currently. The ECLO signposts North Wales residents to the LVSW services available. The post in Ysbyty Gwynedd is currently funded by RNIB until February 2015. BCU will need to secure continued funding for ECLO services to continue beyond this date. September 2014

• Activity of ECLO funded by RNIB is reported quarterly, which includes information on signposting to LVSW . This information is to be collected for all 3 sites from May 2014.

Increase in referrals to LSVW services

Nia Jones/ RNIB ECLO services co-ordinator

Work with ophthalmologists to ensure that everyone entitled to certification as sight impaired is certified

• Audit to be undertaken on all three sites to review current compliance

• Results of audit to be shared at the Regional Ophthalmic meeting

Increase in number of patients certified

Helen Juckes-Hughes/ John Mathews

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• Non compliance to be addressed where appropriate.

Work with the Regional Optometric Advisors in PHW, Optometrists, Ophthalmologists, GPs, CSSIW and the third sector to promote LVSW and improve uptake.

• Need to improve the service in Wrexham prior to commencement of public awareness campaign as there is currently no uptake from Optometrists to undertake LVSW work.

• ECLO services to continue advising patients of the LVSW service

• Review information collated by the North Wales Vision Impairment Benchmarking Group which includes social services and third sector data. September 2014

• Optometry Liaison Group to Monitor LVSW activity to ensure improvement in uptake. August 2014

Increase in LVSW activity

Regional Optometric Advisor/ Optometry Liaison Group/ ECLO Co-ordinator/ North Wales Vision Impairment benchmarking Group/

Work with LVSW and optometrists to ensure 2 way referral between falls clinic and audiology

• ECLO Questionnaire for completion includes questions on falls and ECLOs signpost to falls clinics where appropriate.

• Discuss with RNIB the opportunity

Referrals to LSVW increased

Optometry Liaison Group/RNIB ECLO Co-ordinator

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for adapting the questionnaire to include the same for Hearing and referrals to audiology.

• Review falls clinic documentation to include signposting to Optometry where appropriate.

• Review audiology documentation to include signposting to Optometry where appropriate.

• Review feasibility of Hospital domiciliary visits enhanced service by the Optometrists for long stay patients