North Birmingham: Glaucoma Pilot

Aim of your project

The overall aim of this pilot is to test the feasibility of providing secondary care services in primary care, in the context of chronic eye disease, to alleviate the pressures on the secondary care system. At the same time, by improving and accrediting the skills of Optometrists working in primary care, with an interest in chronic disease management, this pilot will also test the capacity available in primary care to further develop the role of the optometrist with a special interest in the provision of more convenient and accessible services for patients with chronic eye conditions.

The project will determine the educational, equipment and IT requirements, and the most appropriate service model for the establishment of a transferred care service for patients with ocular hypertension and glaucoma within the health economy served by Good Hope Hospital. Responsibility for the initial filtering of all new referrals for suspected glaucoma and ocular hypertension and the monitoring of suitable stable ocular hypertensive and glaucoma patients will be transferred from the hospital eye clinics to a cohort of highly trained and accredited, primary care community optometrists with a special interest in glaucoma. This will reduce the demand on the heavily overburdened eye department at Good Hope NHS Trust, enabling the health economy to meet the NHS Plan access targets, whilst at the same time developing new and improved patient pathways for an enhanced service across primary and secondary care.

The development of IT links is critical to the success of this pilot. Modern, well-resourced care pathways require IT solutions which provide the facility for rapid transfer of information between participating clinicians across the primary/secondary care interface. The assumption that this will be adequately resourced is an underpinning principle, critical to the success of the pilot.

What organisations will be involved in and supporting this application? Why do you believe they are crucial to your proposal?

Objectives of the project - why do you want to be a Pilot Scheme?

Pilot status will allow the key stakeholders to set up and develop the service, proving its effectiveness, without it becoming necessary for the PCTs involved to divert funding in the first instance from an ophthalmology department with serious capacity problems.

Once the service has been fully developed it will provide a model for similar projects involving other important eye disease pathways and general direct referral from optometry to secondary care, which can, where appropriate, be adopted throughout Birmingham and beyond.
Primarily, this pilot allows local stakeholders to develop a first class and cohesive service for patients with glaucoma/ocular hypertension; one which is provided by the most appropriate health care professional without unnecessary delays inherent in the current patient pathway.

Where do you want to be in 2 years' time? Describe your vision for the delivery of Chronic Eye Disease Services

Accredited optometrists with a special interest in glaucoma, situated at convenient locations throughout the health economy, will assess all new glaucoma/ocular hypertension referrals within two weeks of initial referral by a non-accredited health professional.

Inappropriate referrals will be filtered out and those patients returned to the care of the initial referrer, saving many unnecessary new hospital outpatient appointments.

Patients with actual referable disease will be fast tracked to secondary care for final diagnosis and initiation of treatment and patients with ocular hypertension will be fully assessed in primary care. Those not requiring treatment will be monitored by accredited primary care optometrists until a change in status indicates that referral to secondary care is appropriate.

Patients with ocular hypertension assessed as requiring treatment will be referred routinely so that treatment can be initiated; they will then be transferred back to an accredited optometrist in primary care for ongoing monitoring.

Existing diagnosed, treated and stable patients with glaucoma or ocular hypertension will have their ongoing care transferred to an accredited optometrist close to their home.

Accredited optometrists will provide one session per week in the department of ophthalmology (on a rota basis), thus increasing capacity in the department and maintaining regular contact with the secondary care glaucoma team for training purposes.

Relevant patient details and information will be transferred from secondary to primary care and vice versa via a highly developed IT package, and appropriate bookings will be made via electronic means for patient visits to the Hospital Eye Service.
Applanation tonometry, pachymetry, gonioscopy, digital optic disc imaging and standardised full threshold field tests will be used routinely by all accredited optometrists.

Most significantly, up to 250 new outpatient appointments and 1,250 review appointments per annum will have been moved from secondary to primary care. This will allow the department of ophthalmology to focus on delivering a service for more complex conditions and to meet the current and future waiting time targets.

Scope and focus of the project - what aspects of Chronic Eye Care services do you want to develop? What new ideas do you want to test?

It is intended that, in the first instance, the project will develop services for patients with glaucoma and ocular hypertension. This is based on the knowledge that the investigation and monitoring of glaucoma accounts for more than15% of all eye department outpatient clinic activity.

New ideas

a) Education

Optometrists wishing to be involved will be required to attend an intensive course in glaucoma and its differential diagnosis and treatment. This will consist of twenty hours of lectures delivered by an internationally renowned specialist in glaucoma, hands on experience in hospital glaucoma clinics and practical skills training followed by regular update lectures and hospital clinic. This level of training will be substantially higher than has ever been delivered before to optometrists involved in the care of patients with glaucoma or ocular hypertension.

b) Referral Pathways

Having received the education and achieved accreditation, by means of both practical and written examination, the optometrists involved will be expected to confidently receive referrals from non-accredited colleagues and GPs, make a full assessment and decide whether further assessment and initiation of treatment by a consultant ophthalmologist is indicated. The accredited optometrists will monitor cases of ocular hypertension not requiring treatment without recourse to the opinion of a consultant.

c) Standardisation of Equipment

There will be total standardisation of equipment used in the hospital eye department and the primary care locations so that easy comparison of test results will be possible. This will include major slit-lamp, Goldman applanation tonometer, Humphrey Visual Field Analyser, two mirror gonioscopy lens, pachymeter, digital fundus imaging equipment, a computer loaded with appropriate software and a broadband Internet link. This high level of equipment specification and its total standardisation, combined with highly trained professional input, is intended to reduce the number of stable patients who return to secondary care to less than 15%, a figure not achieved by any previous project of this nature.

d) Transferred Care

The concept of ‘shared care’ between secondary and primary care is considered to be somewhat ambiguous in terms of medico-legal responsibility. The proposed scheme addresses this issue by introducing "transferred care". The investigating optometrist will discharge patients and transfer them from primary care to secondary care. Similarly, stable patients taking the opposite route for monitoring will be discharged from the hospital and transferred to the care of the accredited primary care optometrist.

e) Improved diagnostic facilities in primary care

For the first time it is proposed that primary care optometrists will, using all the equipment at their disposal but with particular emphasis on pachymetry and gonioscopy, decide whether patients with ocular hypertension need to be treated to prevent the onset of glaucoma.

Once treated and stabilised these patients will be transferred back to primary care optometry for monitoring.

f) Electronic links

Previous service models have depended on referral between providers using postal or telephone methods. With direct referral from optometry to ophthalmology about to become a reality and e-booking being a requirement by the end of 2004 there is a need to investigate ways in which primary care optometrists can connect electronically with secondary care providers. It is intended to develop an IT model capable of sending digital images Humphrey field plots and all other relevant information between providers.

How can being a pilot help you to achieve your vision?

Whilst there is a commitment from the relevant PCTs to improve eye services within the Good Hope health economy, resources are extremely limited. This is due largely to the capitation position of the largest commissioning organisation and other inherited cost pressures. In order to standardise the equipment used at each accredited site major capital investment will be required, although the revenue costs are extremely competitive when compared with the cost of the current Hospital Eye Service. Pilot status will enable new models of care to develop fully out with the pressures of delivering the existing service.

What are the short, medium and long-term benefits for:

a) Patients

In the short term patients referred with suspected glaucoma to the department of ophthalmology at Good Hope NHS Trust will notice a dramatic reduction in the time taken from first contact with a health professional to receiving a definite diagnosis or the all clear. The diagnostic appointment will be available closer to the patient's home and at a time of their own choosing.

Because inappropriate initial referrals will not be sent to the secondary care provider there will be an immediate small reduction in activity in the Good Hope ophthalmology department. This will make it possible for those requiring access to a consultant to be seen earlier and have their treatment regimen established sooner.

In the medium and long term waiting times for the Good Hope ophthalmology outpatient clinics will be considerably reduced for all patients.

b) Staff

The optometrists chosen to train as Community Optometrists with a Special Interest (COSIs) will benefit from the extensive training and major expansion of their role offered by the project. Hospital Eye Department staff will, immediately, benefit from a 50% reduction in the number of inappropriate glaucoma referrals received in the department giving staff more time to devote to patients requiring full assessment, counselling and treatment.

Later, as stable patients are moved from secondary to primary care, eye department staff will find that patients are able to access their services sooner after referral than has recently been the case. The consequent reduction in complaints will considerably reduce stress and improve morale in the department.

Increased clinical input will bring greater job satisfaction for the COSIs in the longer term.

b) Organisations/local health economy

Good Hope NHS Trust has major financial and organisational problems, to the extent that the management of the Hospital has recently been "franchised". Ever since the Birmingham PCTs were established in April 2002 the Good Hope "situation" has been a major concern. Ophthalmology, because of the poor ratio of FTE consultant ophthalmologists to population served, is one of the departments causing greatest concern. Currently, a significant number of new referrals to the department are being transferred to a private facility some 15 miles away from the Trust location. This has been instigated to relieve some of the pressure on the local eye department, and ensure the meeting of Government targets.

Transferred patient episodes are carried out at higher cost than would be the case at Good Hope, thus introducing a significant financial risk for the PCTs purchasing ophthalmology services.

Whilst it will take some time to bring matters under control, the longer term aims of the project will be to make it unnecessary to transfer any patients and see all new and review patients within target waiting times.
In addition, as the lessons learned from the project are extended to other aspects of eye care, it is expected that the vast majority of inappropriate ophthalmology referrals will be eliminated and much more routine monitoring will be moved into the less expensive primary care environment.

Who are the key stakeholders and potential leaders in your scheme and why?

Potential leaders of the service are:

Proposed project management arrangements

The project management board (consisting of a PCT service development manager, one consultant ophthalmologist, one senior hospital optometrist, one member of NBPCT Professional Executive Committee (an optometrist), the optometric clinical governance facilitator for North and Eastern Birmingham PCTs, two community optometrists and one lay person/service user) will provide both clinical and corporate management for the project.

General administration of the project will be carried out by an administrative officer based either at NBPCT headquarters or within the department of ophthalmology at Good Hope NHS Trust.

How will the success of the project be measured?

A baseline assessment of current time taken to access ophthalmology services subsequent to referral, appropriateness of referrals reaching Good Hope department of ophthalmology, total numbers of patients seen in the department etc will be carried out whilst initial training is undertaken. Throughout the project the same information will be collected for all patients involved.

Success will be measured by:

What are the challenges and barriers to the success of the project? How will these be overcome?

Insufficient interest from community optometrists in becoming COSIs: Whilst this is unlikely, since the areas involved are served by optometrists already known to be committed to service development, members of the management board have previous experience of persuading colleagues to become involved in previous developments such as diabetic retinopathy screening.

Inability of optometrists to meet the educational requirements: A very experienced and highly motivated ophthalmologist, who has been delivering regular lectures to the optometrists likely to be involved for the past five years, will deliver the training. Whilst standards will be set at the very highest level the style of delivery will be such that learning will be an enjoyable experience for everyone involved. Only optometrists with an already proven track record of continuing professional development will be admitted to the training.

Patient reluctance to have their case handled by an optometrist rather than an ophthalmologist: Optometrists in the area are already well respected by their patients but nobody will be forced to switch from HES to primary care. Members of the project management board have already met with a patient forum that received the proposal well. There will be further patient involvement and concerns will be addressed by the NBPCT Patient Advice and Liaison Service and members of the management board.

Resentment by non-participating optometrists in the area when their patients are sent to "competitors" for assessment and/or monitoring: Every optometrist in the area covered was invited to take part in the project from the start. One of the "rules" will be that patients should be advised to return to the original referring optometrist for routine refraction and dispensing when appropriate.

Capacity in Primary Care: The proposed transfer of care from secondary to primary care will require optometric input equivalent to as many as 2 full time equivalent optometrists. Many of the practices likely to be involved currently operate on a part time basis. Whilst current primary care capacity is not fully utilised it will, if necessary, be possible to expand capacity by accredited optometrists providing more input to the practices in the catchment area. Locum optometrists will easily replace loss of capacity in other areas.

PCT pick-up of recurrent costs beyond the life of the pilot: The PCTs involved in the project are fully committed to funding the revenue consequences of the proposed service into the future.

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