Optimising the Optimising the Primary/Secondary Care Primary/Secondary Care

Interface in Eye care ServicesInterface in Eye care Services

Richard BestRichard Best

Belfast Health and Social Care Belfast Health and Social Care TrustTrust

OphthalmologyOphthalmologyHospital Eye Service Hospital Eye Service

One of the largest outpatient specialties in One of the largest outpatient specialties in NHSNHS

Rapidly evolving Rapidly evolving Changed from observation to interventionChanged from observation to interventionHigh volumes of patientsHigh volumes of patientsDay case surgeryDay case surgery

OphthalmologyOphthalmology

Accurate diagnosisAccurate diagnosisTechnological advancesTechnological advancesMore treatmentsMore treatmentsMore patientsMore patients

Pressures on OphthalmologyPressures on Ophthalmology

More referralsMore referralsAgeing populationAgeing populationChronic disease management-diabetes Chronic disease management-diabetes

COAG, ARMDCOAG, ARMDLimited resources Limited resources

(Staff/Equipment/Facilities)(Staff/Equipment/Facilities)Guidelines informing practice (NICE)Guidelines informing practice (NICE)

NHS in UKNHS in UKChange in last 10 yearsChange in last 10 years

Large increase in funding (6%GDP to Large increase in funding (6%GDP to 11%GDP)11%GDP)

Macromanagement tools (access targets)Macromanagement tools (access targets)Targets have become standardsTargets have become standards? Sustainable? Sustainable

Current ProblemsCurrent Problems

Demand exceeds supplyDemand exceeds supply10% rise in number of referrals10% rise in number of referralsHeavy use of IS to increase provisionHeavy use of IS to increase provisionFinancial constraintsFinancial constraints

SolutionsSolutions

Increase funding/increased provisionIncrease funding/increased provisionWaiting listsWaiting listsEffective use of resourcesEffective use of resourcesLook at current model – is it appropriate?Look at current model – is it appropriate?

Increased Funding/ProvisionIncreased Funding/Provision

Outpatient waiting lists behave as a Outpatient waiting lists behave as a complex system that resists changecomplex system that resists change

Appear self regulating ‘power laws’Appear self regulating ‘power laws’Obey their own lawsObey their own lawsSimilar to traffic jams/avalanchesSimilar to traffic jams/avalanches

Shorten waiting lists increase referralsShorten waiting lists increase referrals

Smethurst et al Nature 2001

Ideal ModelIdeal ModelPatient FlowPatient Flow

Tertiary Care

Secondary Care

Primary Care

General Population

Actual ModelActual Modelin Ophthalmologyin Ophthalmology

Population

Primary Care

Secondary Care

Tertiary Care

Primary CarePrimary Care

GPsGPs ‘‘Gatekeepers’Gatekeepers’Triage and assessmentTriage and assessmentProvide appropriate treatmentProvide appropriate treatment

Primary Care in OphthalmologyPrimary Care in Ophthalmology

GPsGPsUndergraduate trainingUndergraduate trainingGPWSi s (postgraduate training)GPWSi s (postgraduate training)Allied Health ProfessionalsAllied Health ProfessionalsOphthalmologistsOphthalmologists

Primary Care in OphthalmologyPrimary Care in Ophthalmology

Embrace skills of those working in primary Embrace skills of those working in primary care settingscare settings

Decentralisation of heavily populated Decentralisation of heavily populated central unitscentral units

Allow recruitment of flexible practitioners Allow recruitment of flexible practitioners to practice in Primary care setting but with to practice in Primary care setting but with strong links to the centrestrong links to the centre

Primary Care in OphthalmologyPrimary Care in Ophthalmology

Refinement of referrals Refinement of referrals Referral guidelines (Local development)Referral guidelines (Local development)Shared Care for chronic conditionsShared Care for chronic conditionsManaged Clinical NetworksManaged Clinical Networks

Primary Care in OphthalmologyPrimary Care in OphthalmologyReferralsReferrals

Good referral should ensure that the right Good referral should ensure that the right patient accesses the right service or patient accesses the right service or specialist at the right timespecialist at the right time

Interventions to Improve Quality of Interventions to Improve Quality of ReferralsReferrals

TriageTriageReferral guidelinesReferral guidelinesActive educational input from local Active educational input from local

secondary care specialistssecondary care specialistsStructured referral sheetsStructured referral sheets

Shared CareShared Care

Post op reviewsPost op reviewsChronic diseasesChronic diseasesTelemedicineTelemedicineCombined clinics (specialist and primary Combined clinics (specialist and primary

care team)care team)

Managed Clinical NetworksManaged Clinical Networks

Linked groups of health professionals from Linked groups of health professionals from primary secondary and tertiary care primary secondary and tertiary care working in a coordinated manner working in a coordinated manner unconstrained by professional and unconstrained by professional and organisational boundariesorganisational boundaries

Thank youThank you