natpact works with primary & care trusts to help them learn & grow together, as connected...
TRANSCRIPT
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
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 Pathway1. Patient reports sight problem to GP2. Patient goes to optometrist/OMP for sight test and
optometrist/OMP refers patient to GP3. Patient goes to GP, referred to HES4. Patient seen at HES, cataract confirmed, decision to
operate, and put on waiting list5. Patient attends HES for pre-op assessment6. Patient attends HES for day case surgery7. Patient attends HES for 24 hr check8. Patient attends HES for 6 week check, 2nd eye
discussed9. 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
Perc
en
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
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
SELFSELFREFERRALREFERRAL
REFERRED BY REFERRED BY ANOTHER CLINICIAN OR ANOTHER CLINICIAN OR
CARERCARER
REFERRED BY REFERRED BY ANOTHER CLINICIAN OR ANOTHER CLINICIAN OR
CARERCARER
OTHER SOURCEOTHER SOURCEOTHER SOURCEOTHER SOURCE
NOT NOT ARMDARMD
NOT NOT ARMDARMD APPROPRIATE APPROPRIATE
CARE ASCARE ASINDICATEDINDICATED
APPROPRIATE APPROPRIATE CARE ASCARE AS
INDICATEDINDICATED
SYMPTOMS SUGGESTIVE OF ARMDSYMPTOMS SUGGESTIVE OF ARMDSYMPTOMS SUGGESTIVE OF ARMDSYMPTOMS SUGGESTIVE OF ARMD
‘‘DRY’ (NON-NEOVASCULAR)DRY’ (NON-NEOVASCULAR)ARMDARMD
‘‘DRY’ (NON-NEOVASCULAR)DRY’ (NON-NEOVASCULAR)ARMDARMD
‘‘WET’ (NEOVASCULAR) OR WET’ (NEOVASCULAR) OR SUSPECTED ‘WET’SUSPECTED ‘WET’
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
DIRECT REFERRAL TO HES FOR DIRECT REFERRAL TO HES FOR FLUORESCEIN AGIOGRAPHY FLUORESCEIN AGIOGRAPHY
ANDANDFURTHER INVESTIGATIONFURTHER INVESTIGATION
TREATABLETREATABLETREATABLETREATABLE
UNTREATABLEUNTREATABLEUNTREATABLEUNTREATABLE
ACCESS TO TREATMENTACCESS TO TREATMENTACCESS 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
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
Delivering Effective Patient Choice in Cataract Surgery
Ann Wagner
Programme 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
West Yorkshire Patient Choice Cataract Pilot
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
West Yorkshire Patient Choice Cataract Pilot
Choice Objectives:
• Targeting long waiters
• Choice in secondary care
• Choice in primary care
To support West Yorkshire Health Community in delivering choice for all
West Yorkshire Patient Choice Cataract Pilot
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?
West Yorkshire Patient Choice Cataract Pilot
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
West Yorkshire Patient Choice Cataract Pilot
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 Wagner
Programme Director
West Yorkshire Patient Choice
Tel: 07970 770708, 01274 322537
E mail : [email protected]
