Enhanced eye care in Wales –A new service

• What service do we want?

• How did we get there?

• How do we ensure it is fit for purpose?

What service do we want?

• Appropriate, efficient, fit for purpose community eye care service for patients in Wales

• Accessible for those who need it

• Learn from previous eye care services– Updating and improving for patients

How did we get there?

Started with WECI

Welsh Eye Care Initiative (WECI)

• Welsh Eye Health Examination (WEHE)

• Primary Eyecare Acute Referral Scheme (PEARS)

• Welsh Low Vision Service (WLVS)

Purpose of WECI

• Detect eye problems in individuals at high risk

• Enable early assessment of acute eye problems

• Provide an accessible low vision service

Perceived advantages

• Providing services close to peoples’ homes

• Reduced demand on GP and hospital resources

• More patients managed in primary care

• Better quality of referral from primary to secondary care

• Using facilities and personnel which were under-utilised

The Welsh Eye Health ExaminationThe Welsh Eye Health Examination • An extended eye health examination

• For those who

– have an increased risk of sight-threatening eye disease

– would find losing their sight particularly difficult

• Patients may self-refer, or be referred by their GP

WEHEWEHE

• Uniocular patients

• Patients who are profoundly deaf –need sight to lip read

• Patients with retinitis pigmentosa

• Patients whose family origins are Black African, Black Caribbean, Indian, Pakistani or Bangladeshi

• Those at risk of eye disease by other reasons of race or family history

The Welsh Eye Health The Welsh Eye Health Examination - WEHEExamination - WEHE

Black and Minority Ethnic groups

Condition Odds Ratio

Diabetic Retinopathy 2.96 Blacks vs Whites

Chronic Open Angle Glaucoma

5.0 Blacks vs whites

Cataract 5.25 Asians vs whites

Increased risk of sight-threatening eye disease:

PEARS

• Anyone with an eye condition that needs urgent attention

• Patients can self-refer

• An appointment within 24 hours

The Primary Eyecare Acute Referral Scheme

• Optometrists must have specified equipment in their practices

• Optometrists did theory training and were assessed

• Approximately 90% of all optometrists in Wales are accredited

Training and accreditation

Assessments

What optometrists learned

Increased use of a Volk lens and/or dilating a patient (23.4%)

Increased confidence dealing with cases of ocular pathology (17.7%)

27.5% described the experience as ‘traumatic’

WEHE & PEARS Service Evaluation

Evaluation

• An evaluation was carried out

• Customised records cards were filled in by optometrists

• Referrals scrutinised

WEHE & PEARS evaluation

• 6,432 record cards were reviewed

• 66% of patients were managed in practice (i.e. not requiring GP or Hospital visit)

• 99% appropriate referrals by optometrists

• 100% patients satisfied

Sheen NJL et al. Novel optometrist-led all Wales primary eye-care services: evaluation of a prospective case series Br J Ophthalmol 2009;93:435-438

Welsh Low Vision ServiceWelsh Low Vision Service(WLVS)(WLVS)

Welsh Low Vision ServiceWelsh Low Vision Service

• A rehabilitation service for people with a visual impairment

• Based in 185 optometry practices

• Practitioners accredited by Cardiff University

• Anyone can refer including patients themselves

WLVS

A range of low vision aids

Welsh Low Vision Service

Welsh Low Vision Service - Holistic

•Multi-disciplinary sessions during training

•Training for rehabilitation workers and specialist teachers

Court H et al. British Journal of Ophthalmology 2010

Just as effective as the hospital service

Comparing hospital and community low vision services

•No significant difference in clinical outcomes

•No significant differences in user centred outcomes

•Disability significantly reduced after low vision service

•Improved access

Proven services that are effective

•Low Vision

•PEARS/ WEHE

Why change?

Changes to PEARS/ WEHE needed

• There are categories of patients at risk of eye disease that were not covered

• Ethnicity categories not well defined

• PEARS/ WEHE/ WECI can be confusing

• No permanency to services

• Clinical guidelines had changed

• Focus On Ophthalmology

• Potential to alleviate hospital eye service capacity issues

Changes to PEARS/ WEHE needed

What has changed

• Updated

– Name of services

– Structure – further categories

– Clinical guidelines

– Referral forms

– Service guidelines

Name of services

• Welsh Eyecare Initiative now becomes

Wales Eye Care Service (WECS)

• PEARS/ WEHE are now amalgamated to single service

Eye Health Examinations Wales (EHEW)

• Welsh Low Vision Service now becomes

Low Vision Service Wales

• Introduces new categories for:

– referral by DRSSW

– monitoring dry AMD yearly

– cataract referral refinement

Eye Health Examination Wales (EHEW)

• Other improvements:

– Reporting of ethnicity and clarification of ethnicity categories

– ONS Census linked

Eye Health Examination Wales (EHEW)

• Guidelines for referrals, emphasis on:

– Optoms to repeat Intra-ocular pressure readings with Applanation tonometry

– Optoms to repeat visual field examinations

Eye Health Examination Wales (EHEW)

Clinical guidelines

AMD monitoring - Dry AMD

•Advice about lifestyle and what to do if sudden drop in vision etc

Cataract – Referral refinement

•Guidance about discussing with the patient and a questionnaire for the patient to complete

• New referral to ophthalmology form

– Paper and electronic

• New report to GP form

– Paper and electronic

Referral and report forms

Referral form Report to GP

EHEW

How do we ensure it stays fit for purpose?

Evaluation and Audit

• Service guidelines and new forms make it easier

• Regular audit

• Evaluation of referrals

• Findings from audits will feed into training

Training

• Benefits gained should outweigh cost

• Training programmes should focus on evidence based practise and should always display strong links to desired outcomes (Mays 2004)

• We need to ensure it has an positive effect on behavior

Training – peer review

• Peer review as a vehicle for communicating results of audits and changes to service

• Cases used to embed learning outcomes for optometrist practitioners

• Discussing cases makes it ‘real’

• Evaluate impact that peer review has

Service review

Conclusions

• We seek to have the best service possible for those patients who need it most

• We will continue to evolve the service by evidence based evaluation and training

• We believe that we have a service that will be fit for purpose

Ensuring changes are communicated

• GPs

• Ophthalmologists

• Third sector organizations

• Other healthcare workers

• Patients!

Without whom..

• WG- Richard Roberts & Sarah O’Sullivan-Adams

• OW – Sali Davis & Mike George

• WOC – Ian Jones & committee

• WOPEC – Barbara Ryan

• Optometrists in Wales

Thank you

Questions?