‘Optimal Models of Eye Care’ policy roundtablesImproving eye care commissioning – notes from roundtable meeting 19 July 2017, Leeds

In February 2017, The Royal College of Ophthalmologists (RCOphth) published a surveillance report of patients losing vision due to delays in treatment and follow-up appointments. The research, carried out by the British Ophthalmological Surveillance Unit (BOSU), found patients suffering permanent and severe visual loss due to health service initiated delays; the research showed that up to 22 patients per month losing vision by such delays [1].

The College of Optometrists has commissioned research resulting in published papers evaluating different models of primary and community eye care. The recently published ”The Way Forward” (2016) series of reports, highlighting the need for services to adapt to improve efficiency and sustainability ”in the face of such growing disparity between demand and resource”[2].

This fifth in a series of RNIB roundtable discussions brought together a cross professional group of experts [see Appendix 1] to explore how patients can be at the heart of considerations when developing minor eye condition schemes. This final policy roundtable focused on how to improve eye care commissioning in England.

Setting the sceneEnsuring patients are at the forefront of considering how to respond to capacity problems is crucial for RNIB. A rapid review of the literature on patient perspectives of minor eye condition schemes was carried out. This led us to three key questions for discussion:

Q1. What is needed to improve commissioning to ensure eye care capacity meets demand to prevent avoidable sight loss?

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Q2. Should we seek to secure the holistic commissioning of integrated eye care services across all specialities? What evidence is needed to facilitate this?

Q3. How can we raise the priority of eye care in England?

These questions formed the basis of the roundtable discussion. Presentations from a number of individuals gave additional stimulus to the conversation.

A patient’s view Helen Lee, a Policy Manager at RNIB first gave a brief overview of key learning from the four roundtables to date which have covered: Glaucoma referral and monitoring Neo-vascular Age-related Macular Degeneration (AMD) Pre- and post-operative cataract services, and Minor Eye Condition Services.

Helen outlined how previous roundtables had emphasised how essential it is to put the patient experience at the centre of service design. The following key measures can help to achieve this: Services being streamlined so where possible patients can

have the appropriate tests, reviews and treatment all in one visit. This is particularly essential as many patients are elderly and/or unable to drive, so attending multiple appointments can be very challenging for them.

Patients being given support to know and understand their treatment regimes, so they are able to adhere to treatment, follow up delayed or cancelled appointments, e.g. such as the ‘Get to Grips With Glaucoma’ programme in Manchester.

Innovative models of eye care using the right health professional in the right setting with the right expertise and skills. Building trust amongst professionals both locally and nationally is needed.

Currently efficient patient friendly models of care are established by passionate committed clinicians. There needs to be mechanisms established to facilitate the implementation of good practice more consistently.

Proper service planning is essential based on eye health needs assessments which anticipate demand rather than responding to the issue of capacity. Inequalities in access and outcomes

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need to be considered throughout to ensure those most at need of services receive them to prevent avoidable sight loss.

Work is needed to change the public’s perception of optometrists so that their expertise in eye health is recognised and a sight test is seen as a health check.

Also, the broader eye health work of optometrists needs adequate funding; as currently the retail dimension of optometry is a barrier to accessing sight tests particularly for people experiencing low income.

Establishing IT-systems that enable the secure transfer of patient data, sharing examples of good practice such as the IT solutions established for mobile AMD services.

Prioritising eye care within health service commissioning and planning e.g. for its inclusion in Sustainability and Transformation Plans/ Partnerships (STPs) priorities, and securing political recognition of the value of eye health and the need for adequate resourcing.

Helen concluded that a collaborative approach is essential to ensure the patient’s experience is at the centre of service design –bringing together non-governmental agencies, health services, health professionals, commercial organisations and most importantly people living with sight loss or at risk of sight loss is needed. By working together we can develop and provide robust and convincing evidence to win the hearts and minds of policy makers and service commissioners.

Q1. What is needed to improve commissioning to ensure eye care capacity meets demand to prevent avoidable sight loss?Participants made the point that NHS targets and tariffs are driving practice and service provision rather than clinical decision making. One solution might be more clinically relevant targets, a standardised approach led by clinicians.

There needs to be better coding and standardisation of ophthalmology data to provide detailed information to commissioners to facilitate efficient service planning.

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Valuable learning can be gained from how other areas of health care, commission, plan and deliver services. The example of the NHS London Stroke Strategy was discussed which developed specialist high-risk centres and step-down services, by looking at need, reconfiguring services and preventing duplication to ensure an effective care pathway was put in place. It was felt that the current situation of eye care is similar to the early days of the cancer networks and we can learn from the development of the work around cancer services.

It was also felt there is a need to look strategically to plan for sufficient eye care capacity to meet demand for patients regarding their eye care, because failing to meet patient need can lead to an increase in this demand and, also for other areas of health or social care issue e.g. due to falls from sight loss. However, the health system does not currently see these as an eye health issue.

Both government and the NHS need to urgently recognise that patients themselves often see their own eye health as a relatively higher priority than is currently recognised in terms of the impact upon people’s overall wellbeing, including if they are dealing with multiple health conditions.

Effective commissioning of integrated eye care services David Parkins, from the College of Optometrists and Vice Chair of the Clinical Council for Eye Care Commissioning (CCEHC) gave a presentation on effective commissioning of integrated eye care services across all specialities.

David began with a brief overview of the different health systems across the UK’s four countries, and made the point that despite this variation, they all appear to be grappling with the challenge of an increase in patient demand and the capacity challenge this raises for their eye health services.

David ran through the wealth of guidance that has been produced about the commissioning and delivery of eye care services by NICE, RCOphth, College of Optometrists, along with the CCEHC.

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David mentioned recent political interest in eye care services. This includes the work of the London Assembly Health Committee which issued a consultation on Eye health and preventing sight loss in London from mid-June to 31 July 2017. It will make recommendations to the Mayor of London who has a duty to produce a strategy to promote the reduction of health inequalities among Londoners.

There has also been rising interest in Parliament. Nusrat Ghani MP, the former Chair of the All-Party Parliamentary Group (APPG) on Eye Health and Visual Impairment, led a Parliamentary debate on Preventing Avoidable Sight Loss on the 28th March – the first of its kind for many years. David also cited a 5th July written question from Jim Shannon MP (the new Chair of the APPG) to the Department of Health (DH), asking the Secretary of State what they are doing “to promote to health commissioners the role that community optical practices can play in delivering eye care services”. However, the DH Minister’s response just referred to the role of CCGs on decisions about eyecare commissioning, and emphasised NHS England’s work with the CCEHC in developing guidance for CCGs on clinical pathways for eye health.

David referred to the CCEHC’s Framework Principles and made the point it makes clear that “patients [should] be managed in the most appropriate service according to risk stratification of the condition and skills of the practitioner”.[3] He also referred to the CCEHC’s “Low Vision, Habilitation and Rehabilitation Framework for Adults and Children” (LVHRS), which: “promotes integration across primary and community care, hospital eye service, education, social care, voluntary services, and stroke, rehabilitation and falls teams to deliver better outcomes, and eliminate duplication and waste of resources.” [4]

David highlighted NHS England’s concern in the “Next Steps on the NHS Five Year Forward View” to reduce unwarranted variations in eyecare that exist for patients across England, which it says: “cannot be explained by differences in health need and are often present between different GPs in the same area and different doctors in the same hospital.”[5] This variation is substantiated by the 2017 BOSU-study which shows up to 22 patients per month are their losing vision due health service initiated delays[6]. David suggested there is a need to look for standardisation.

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The draft NICE glaucoma guidance consultation (June 2017) involves discharging a new cohort of patients who are low-risk to primary care, and require a discharge summary going to optometrists and provision for glaucoma repeat measurements to avoid re-referral. This will require joint working between primary and secondary care. However, NICE has evaluated how the repeat measures (Glaucoma Quality Standard) should work in practice but found that patients do not respect CCG boundaries, non-participating practices dilute effectiveness of the standard, and a disproportionate amount of time and resource is spent on commissioning ‘repeat measures’ multiple times.[7] David said this indicates a need to commission at scale for greater efficiency.

David highlighted the importance of an agreement on sharing patient information between ophthalmologists and optometrists which was agreed by the RCOphth and the College of Optometrists in 2015, this needs to be more widespread in order to modify referral patterns.[8]

David concluded by contrasting the traditional referral route for eyecare with a ‘RightCare’ approach [9]: ‘Traditional’ - in which GPs have had a central role for patients

in referring them to secondary care following a sight test normally only every two years. It is characterized by only single appointments, no follow up or repeat measures, it is not an acute service and there are minimum recall intervals.

‘RightCare’ – involves primary eye care service and a community multi-professional team, managing moderate risk and stable eye conditions in a community setting. It utilises NHS e-Referrals and has replies to referrals, retains more patients, and is integrated because it considers eyecare in relation to other health conditions/ issues e.g. smoking, falls, stroke and dementia. It also involves an integrated LVHRS between the health, social care, charity and voluntary sectors.

David said a RightCare approach would help to keep more people in primary care but this depends upon an effective joint commissioning strategy being in place.

Participants felt that more integrated care is needed with optometry and ophthalmology working together effectively, to avoid

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duplication and to share patient information, which is in patients’ interests. It was noted that this is already being practiced in London through an e-pilot.

GPs however, remain responsible for prescribing and must therefore remain within the eyecare pathway unless optometrists are allowed to prescribe. This is already happening in Scotland where 300 optometrists can prescribe. This figure may increase and could reduce pressure on GPs. For example, in Lambeth and Lewisham it has led to a 26.8 per cent reduction in first attendances from GPs to ophthalmology. It was also felt that patients would benefit from greater clarity about whether they should go to see their GP or an optometrist for their eyecare, and that a standardised care pathway was needed.

It was also noted that GPs or a Practice Nurse currently are still the main health practitioner that patients go to for their overall healthcare, including eye care. Although this may change if patients increasingly go direct to optometrists; GPs need support to ensure they provide an accessible service for their eye care patients.

Community ophthalmology Tim Manners an Ophthalmologist in York and Clinical Director at Newmedica gave a presentation about whole service ophthalmology.

In 1990 seven ophthalmologists were working in ten locations around North Yorkshire; compared to 28 consultants working in seven locations by 2017. Over the last forty years, the population of North Yorkshire had increased by 25 per cent. The county’s elderly population (people over 65) has increased by 100 per cent and eye disease affects 95 per cent of old people. Wet AMD is now treatable and cataract operation rates have increased from five hundred in 1968 up to 11,500 operations in 2015.

However, this increase in activity is being provided by fewer centres in acute hospitals – only Sweden has a similar model. This approach began in the 1980s as a centralised anesthesia resource; but anesthesia is now rarely required. Tim said it raises

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the question about how to de-centralize services which could be achieved by: Accepting less central control Incentivizing ophthalmologists to take on the clinical challenges

of running services Partnering with NGOs for finance/ investment, and Keeping strong links with regional teaching centres, because it

is important not to lose the large expert centres and different employment patterns could be encouraged.

A CCG-commissioned service which provides multi-specialty ophthalmology services could provide benefits to the patient and CCG and enable providers to establish themselves relatively easily. Tim illustrated this with the example of Newmedica which has provided Community Services for nine years holds a number of ‘multi-specialty’ contracts and sees 80,000 patient visits a year.

Tim described the model working as follows: If a patient has multiple conditions the clinical team can cross

refer internally to a specialist consultant Personalised treatment plans are used, with planned and

scheduled treatment based upon the patients’ wants and needs Sharing of data across treatment which ensures better

coordination, and The same clinical teams deliver all of a patient’s care and there

is a single point of clinical oversight.

Tim outlined the benefits he sees for patients from: Community locations for all appointments – because it is easy

to access, especially for follow up; the clinical environment; it helps ensure access for hard to reach populations; it ‘normalises’ the eye condition; and is easier to promote self-care, and

Where a patient has multiple eye conditions, it provides them with – patient-centered coordinated treatment; familiarity with the clinical team which may reduce anxiety; and provides a single point of contact for all follows up or questions.

Tim outlined the benefits he sees for CCGs from: More coordinated patient care, with better patient outcomes,

reduced unnecessary appointments, and reduced CCG costs

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As ‘multiple services’ are included, it reduces the number of

contracts (and associated administration) Allows additional providers to deliver the service, without

significant contract burden They receive more coordinated data across all their services

helping improving commissioner oversite It reduces the burden on GPs and associated health

professionals, and Reduces the number of patient ‘drop-outs’.

Finally, Tim outlined the benefits he sees for health providers from this model including: A longer-term investment in people, premises, equipment and

economies of scale It can also help develop innovation, share learning across

specialties and incentivize better patient-centred care Help promote the development of pathways between specialties

and better relationships with community optometrists and the third sector, and

Help reduce unnecessary administration and support better data sharing.

Participants discussed key questions which this model raised including: The current role of the NHS as a teaching organisation, the

costs the NHS carries to fulfil this function and how this affects its outputs, and whether community ophthalmology could also or instead undertake this role.

It would require teaching to be funded within contract specifications; if teaching was funded it could incentivize a change in their business model and make it viable.

There may be concerns about the optometry sector ‘cherry picking’ the more straightforward conditions and surgery, with the lowest risk cases kept in the community, and the highest risk cases remaining with secondary care.

There may be also concerns about undermining the capacity of acute hospitals; and how to achieve this without detracting from their resource as a centre of expertise.

The NHS payment system for eye care is not cost but tariff based and may need to be renegotiated to meet clinical need. As patient numbers and treatments grow the cost/ tariff model will need to change. CCGs do not currently take a whole system

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approach which is leading to private providers being used to patch up the system.

Another observation was that if community optometry grows it may also reach the limits of its capacity.

A concern was also raised that community optometry may undermine the NHS and see a return to a pre-1948 model.

2. Should we seek to secure the holistic commissioning of integrated eye care services across all specialities? What evidence is needed to facilitate this?Several participants suggested that the best way to innovate to improve efficiency in care is via sub-speciality. One participant felt that the NHS has a poor record of successfully commissioning integrated services across specialities. However, there is a real need for planning eye care services across all specialities.

STPs provide opportunities for improving commissioning of eye care, to reduce variation and duplication, as does the move to Accountable Care Organisations (ACOs). ACOs may be more interested in the social care costs incurred as a result of people losing sight.

Some CCGs are of the view that they must share the same framework for eye care commissioning, and there is an opportunity for the CCEHC to provide this to them and coordinate its uptake across England.

Commissioning networked care and delivering integrated eye care across ophthalmology Karen Reeves, the Vanguard Network Programme Manager at Moorfields Eye Hospital gave a presentation about the challenges and opportunities for commissioning networked care and delivering integrated eye care across all ophthalmology specialities. The vanguard has focused on exploring how single specialty networked care can help the sustainability of smaller district general hospitals sustainability, and this work has been codified as an online learning resource [10]. The vanguard has not restricted learning to

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ophthalmology and has found that themes were consistent in terms of challenges for sustainability.

Karen observed the current commissioning system for ophthalmology is unsatisfactory and a sustainable alternative is needed. Moorfield’s year-two vanguard is considering the challenges of commissioning single specialty networked care from both provider and commissioner perspective.

Key issues raised were: In community settings the ability to scale up and achieve a

critical mass. Many community based optometrists are willing to extend their skills more widely; but the small schemes CCGs commission locally are fragmenting a single pathway and taking money out of hospitals that help support the more complex work that consultants need to deliver or supervise.

Private providers have to make a financial return; so optician practices will balance the amount of NHS work over private income. They will be keen to maximise the numbers they can see; but may not have the same overheads as an NHS trust. Having lots of practitioners seeing limited numbers of patients may not be the best solution from a quality and safety perspective.

GP’s with a Special Interest can push through minor eye conditions and operations but are limited in being able to deal with complex conditions/ situations. A small but increasing number of optometrists are prescribers limiting their ability to deal with a wider range of conditions and a limited number of optometrists are glaucoma specialist trained.

Karen commented the above factors limit the scope of what are fragmented small services. However, with proper governance oversight and well trained primary care professionals, many minor low risk eye conditions should never go to secondary care; but the larger volumes such as glaucoma monitoring carry more risk and whoever is clinically monitoring and auditing these services needs to understand ophthalmology. This does not always happen and the risk is then transferred to secondary care when the patient has complications or undetected issues.

Karen said where the ophthalmology pathway begins and ends, is a key challenge for a new commissioning framework which can

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deliver an integrated service. There may also be a case for redefining low risk ophthalmology into primary care, but it is unclear whether this would make it easier to integrate the remaining eye services.

As part of Moorfield’s vanguard research phase they talked to many other organisations providing networked and non-networked care. There was a consensus that one of the biggest problems facing hospitals was staffing, and is seen by many as more pressing than financial pressures.

Karen observed that future sustainability requires pathways to be developed that do not rely on consultants and other doctors to deliver ophthalmology care. However, these pathways will have to be delivered by well-trained staff. She commented that the Five Year Forward View [11] is about quality, safety, clinical outcomes and patient experience.

Karen said, achieving this is dependent upon standardisation which was the second most critical factor cited by the organisations that the Moorfields vanguard spoke to during year one. It is one of the most difficult objectives to achieve particularly when dealing with services at more than one location and between two or more organisations working together. Key to this is embedding standardised pathways and processes at the start of any relationship.

An agreed national approach is required for the development of a standardised and recognised qualifications and nationally recognised staff competencies – this should be driven by health providers and key stakeholder bodies as the commissioning approach to date does not appear to be working. A collaborative approach is needed to replace extensive variation.

The second year of the Moorfield vanguard will: Begin a national collaboration to help drive ophthalmology

clinical standardisation nationally, through consensus between clinical providers and professional bodies, and

Look at the benefits and challenges of ‘stretch’ for the model of eyecare – whether numerical or by distance. Moorfields is also considering the challenges this model represents for regulators and commissioners.

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Moorfield’s key driver for networked care is that there is a fundamental risk to smaller clinical specialties with sustainability which may not be solved by accountable care, group or other models, because the smaller clinical specialties may continue to be lower priority. Clinical networks can address local STP standardisation but not necessarily the investment and staffing issues for the smaller sub-speciality. The critical mass and costs involved make a Moorfields-type networked care model (where there is one lead provider providing the service onto other NHS sites) the more viable solution for an STP-solution. How the primary care-model operates may need the same approach.

3. How can we raise the priority of eye care in England?Participants agreed there is a need to raise the profile of eye health up the political and health agenda and discussed different ways to achieve this.

There was a powerful suggestion that, rather than focusing on sharing solutions, the sector now needs to highlight the risk of not prioritising eye care. Without improving commissioning and planning of eye care services, costs will escalate and the capacity crisis will only increase. The consequences of this need to be made clear to decision-makers. We therefore need to prioritise communicating patient experience, to show people there is a problem that needs to be resolved.

Currently, ophthalmologists often have to spend time responding to patients’ complaints about delayed and cancelled appointments; but MPs are not receiving complaints from their constituents so there is no recognition of the issue.

Compared to the devolved countries there is no consensus in England for a national strategy. It was observed that if eye health was included in the “NHS Mandate” it would raise it as a political priority and within the NHS. There is a need to effectively ‘sell’ to decision-makers how much of a priority eye health actually is to patients.

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There needs to be a focus on delivery and getting decision-makers to prioritise eye-health.

Participants discussed the role of patient empowerment, although recognising it is a diverse population with a high proportion of older people who are reluctant to complain.

There is an opportunity for the CCEHC to provide a coordinating or leadership role on eyecare across the NHS in England with CCGs and STPs, so that they all adhere to the same approach which can deliver national standardisation across different local delivery models around the country.

The APPG on Eye Health and Visual Impairment’s inquiry into capacity problems in NHS eye care services and avoidable sight loss in England will enable the sector to present strong evidence to ensure robust recommendations are identified.

Next steps: Information from all the policy roundtables will be collated by RNIB for submission to the APPG inquiry into improving eye care commission and tackling capacity issues within eye care services. Prior to this the draft notes from this meeting will be circulated for agreement to attendees. It is envisaged that the findings from the APPG inquiry will be used to formulate a sector wide campaign to improve commissioning of eye care services to better meet the needs of the population.

Appendix 1 Jim Barlow, Chair, Former Head of Primary Care, Staffordshire

and Shropshire Ross Campbell, Contributor, Director of Optometry

Advancement UK and Ireland, Specsavers Naomi Charlesworth, Contributor, NHS Portfolio Manager,

Specsavers Simon Dewsbury, Contributor, Health Education England and

Clinical Leadership Fellow, Leeds Teaching Hospitals NHS Trust

Andy French, Note-taker, APPG Eye Health Inquiry Officer Fazilet Hadi, Contributor, Deputy CEO, RNIBrnib.org.uk

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Susan Hoath, Contributor, CEO, Focus Birmingham Helen Lee, Presenter, Prevention Manager, RNIB Tim Manners, Presenter, Ophthalmologist in York and a Clinical

Director at Newmedica David Parkins, Presenter, Vice-Chair of the CCEHC, Immediate

Past President, College of Optometrists Karen Reeves, Presenter, Vanguard Programme Director,

Moorfields Eye Hospital Nizz Sabir, Contributor, Commissioning Lead, Local Optical

Committee Support Unit

References

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1. Foot B, MacEwen C. (2017) “Surveillance of sight loss due to delay in ophthalmic treatment or review: frequency, cause and outcome”. Eye. 31, 771–775.

2. The Way Forward was commissioned by RCOphth to identify current methods of working and schemes devised by ophthalmology departments in the UK to help meet the increasing demand in ophthalmic services. RCOphth (2016) “The Way Forward: Options to help meet demand for the

current and future care of patients with eye disease. Cataract.” RCOphth (2016) “The Way Forward. Options to help meet demand for the

current and future care of patients with eye disease. Glaucoma.” RCOphth (2016) “The Way Forward. Options to help meet demand for the

current and future care of patients with eye disease. Age-related Macular Degeneration and Diabetic Retinopathy”.

RCOphth (2016) “The Way Forward. Options to help meet demand for the current and future care of patients with eye disease. Emergency eye care”.

3. CCEHC – “Primary Eye Care Framework for first contact care” (2016), and “Community Ophthalmology Framework” (2015).

4. CCEHC (2017) “Low Vision, Habilitation and Rehabilitation Framework for Adults and Children”.

5. NHS England (2017) “Next Steps on the NHS Five Year Forward View”.

6. Foot B, MacEwen C. (2017) “Surveillance of sight loss due to delay in ophthalmic treatment or review: frequency, cause and outcome”. Eye. 31, 771–775.

7. NICE (2011) “Avoiding unnecessary referral for glaucoma: use of a repeat measurement scheme”, Bexley Clinical Commissioning Group.

8. Sharing patient information between healthcare professionals – a joint statement from RCOphth and the College of Optometrists (2 March 2015).

9. NHS RightCare is a national NHS England supported programme which is committed to delivering the best care to patients, making the NHS’s money go as far as possible and improving patient outcomes, see www.england.nhs.uk/rightcare/what-is-nhs-rightcare/.

10. Moorfields Vanguard Programme Team. Networked care toolkit. London: Moorfields Eye Hospital NHS Foundation Trust, 2017. Available at: www.networkedcaretoolkit.org.uk.

11. NHS England (2014) “NHS Five Year Forward View”.