East Devon: Glaucoma Pilot
Aim of your project
To modernise East Devon glaucoma care in line with the recommendations of the Eye Care Services Steering Committee by:
- Introducing a New Eye Care Service (NECS) of specially glaucoma trained Community Optometrists distributed at population centres in Optometrists premises throughout the East Devon community, providing a primary care setting with state of the art technolog
- Introducing a Mobile Eye Care Unit (MECU), available to patients unable to travel to HES or Community Optometrists premises, due to physical, mental, social, financial or other such hardship.
- Establishing a centralised Glaucoma Database Register, for use by primary and secondary glaucoma care providers.
What organisations will be involved in and supporting this application? Why do you believe they are crucial to your proposal?
Community Optometrists
They will be participating in the pilot and are crucial to the proposal as they will be offering follow up glaucoma care from their premises to improve access across the East Devon localities.
West of England Eye Unit (WEEU)
Based at the DGH, the Royal Devon & Exeter Hospital. They will:
- Provide Clinical expertise to change the existing care pathways to improve access to services without loss of quality of care.
- Provide Clinical training and support to the Participating Optometrists (POs).
- Audit the quality of optometric care.
East Devon Primary Care Trust
They will provide administrative and management support. The Professional Executive Committee (PEC) of the PCT will have overall responsibility of the new NECS service. The NECS Co-ordinator (NECSCO) whilst working very closely with the Participating Optometrists and the West of England Eye Unit, will be employed by the PCT and be accountable to the PEC through a nominated manager.
East Devon GP Practices
Their support of this new service will be crucial if patients are to have confidence in the new care pathway. GP opinion of the service will influence patient perception.
Local Optometric Committee
They will coordinate optometric involvement including training, design, promotion, clinical care, optometric audit, support and feedback.
North & East Devon Information Community Shared Services for IT
Will be involved in establishing, integrating and supporting the new IT system into the current IT infrastructure.
The South West Peninsula SHA
Who confirm their support for this bid.
Other local organisations
Including Social Services and local Care Homes who will be involved in supporting and enabling access for individual patients who may require the service.
Objectives of the project why do you want to be a Pilot Scheme?
- To reduce overall waiting times for ophthalmic out patient appointments by diverting approximately 16.5% (1500 appointments) of follow up appointments to the participating optometrists. In particular this pilot is likely to have an impact on the delay in
- To provide a quality service and sufficient capacity to meet the glaucoma care needs of the growing elderly population in East Devon. Currently, 47% of the population are over the age of 50, and East Devon is one of the fastest growing areas in the count
- To improve patient access by providing an exemplary glaucoma follow up service, with state of the art diagnostic medical instrumentation within the East Devon community localities, to the same standard as offered in the DGH/WEEU.
- Opportunity to provide glaucoma care to elderly, disabled, or other patients who otherwise would otherwise have restricted access, by providing a) community based clinics established in Year 1; and b) - Mobile eye care unit (MECU) established in Year 2.
- To establish a central database Glaucoma Register which will be available to participating optometrists and consultants based at WEEU.
- To Improve quality of optometric care to the community.
- To Improve inter and intra-professional relationships and communication.
- Opportunity for the staff and organisations to utilize and stretch their creativity, energy, enthusiasm, and innovation to provide better patient care.
- Opportunity to expand clinical skills of community based optometrists.
- To assess the future possibilities of glaucoma care locally, thereby contributing to the health community’s clinical and socio-economic understanding and care of glaucoma patients using optometrists.
Where do you want to be in 2 years' time? Describe your vision for delivery of Chronic Eye Disease Services
- A comprehensive database Register of glaucoma patients being followed up by optometrists within East Devon (for patients who are stable or have ocular hypertension) will be established. The management and administration of the Glaucoma Register will enhan
- These patients will have regular glaucoma follow-up visits by Participating Optometrists at local optometric practices, locally based community clinics or via the Mobile Eye Care Unit (MECU), whichever is more convenient or suitable to the patient.
- The subsequent relief on the WEEU out-patient appointments will reduce waiting times for follow up appointments (for urgent or complicated secondary eye care).
- The new IT system will enable a high level of staff communication and clinical audit capabilities and within 24 months will start to provide a chronological record of glaucoma patients’ progress/deterioration, including stored images.
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?
- Local optometric care for glaucoma follow-up and monitoring for East Devon patients, to test if specially trained and equipped optometrists can provide high quality glaucoma follow-up care effectively while relieving out-patient appointment times at the H
- To test the idea that specially trained optometrists, supported with state of the art equipment in a small number of community practices, geographically distributed in population centres, can provide the same quality of follow up care as is offered in a s
- Mobile Eye Care Unit (MECU) to provide state of the art medical instrumentation to patients within East Devon PCT and other neighbouring PCTs, who otherwise would have problems regularly attending the HES. This will enable us to test if a mobile unit wit
- Establish a Glaucoma Register of glaucoma patients in East Devon to test if the Glaucoma Register can aid in monitoring glaucoma care, improving patient care/patient compliance, providing chronological clinical images and records, statistical analysis and
- To test if a state of the art IT software system can enhance or improve clinical communication among NECS staff?
- To understand the cost effectiveness of an optometrist led glaucoma follow up service compared to the traditional service within a secondary care environment.
How can being a pilot help you to achieve your vision?
Instruments/Equipment
The funds available via the pilot will allow state of the art standardised instrumentation to be placed in PO’s practices in the community and in a mobile unit, in order to provide equivalent level of clinical instrument/equipment support to that offered in a secondary care setting.
Training
The funds will provide training opportunities for the community optometrists to become Participating Optometrists, providing follow-up care for glaucoma patients. Training will include subjective and objective assessment of glaucoma patients including applanation tonometry, optic disc assessment with fundus lens, Humphrey Vision Analyser, and Heidelberg Retinal Tomograph.
IT System
The funds will provide an IT structure for patient data, appointment/recall data, and clinical data transfer as well as the central Glaucoma Register.
N.B. The instruments, clinical training, and IT system are essential to maintaining an equivalent level of clinical care as in a secondary care setting.
Motivation
The pilot has provided the stimulus for local organisations to work together collaboratively and in a multi-disciplinary manner, many for the first time, in order to achieve better patient care and access.
What are the short, medium, long term benefits for:
Patients
a) Short/medium term
- Shorter HES patient follow-up appointment delay times.
- Greater choice/access for glaucoma follow-up appointments.
- Glaucoma register (GR) to monitor patient appointment compliance.
- Improved patient medication and appointment compliance (through the reduction in follow up appointment delay).
b) Long term
- Timely follow up appointments for patients resulting in more reactive therapy with its associated impact on patient care.
- Greater awareness and understanding of glaucoma in the community.
- Improved use of crucial secondary care resources through the provision of routine glaucoma follow ups in a primary care setting.
- Overall saving in travel time and expenses.
- Reduction in time away from work through improved access.
Staff
a) Short/medium term
- Greater awareness and understanding of glaucoma and glaucoma care within participating optometrists practices.
- Increased level of clinical expertise for Participating Optometrists.
- Reduced staff and system stress from reduced appointment times and shorter waiting lists.
- Improved professional status of Participating Optometrists and practice staff.
b) Long term
- With experience community based staff will become more efficient and be able to provide a higher quality of care.
- Opportunities for ongoing learning and development for all involved through integrated multi-disciplinary working, and in particular enhanced ophthalmology/optometry working relationships.
Organisations/local health economy
a) Short/medium term
- Enhance inter and intra-professional coordination and communication.
- Improved data and information on glaucoma patients, which is currently not available.
b) Long term
- Decrease waiting times in secondary care.
- Improve local IT infrastructure.
- The pilot bid has already brought together people whose collective ideas have formed new possibilities for health care. The process of fulfilling the pilot scheme can serve as further opportunity for additional possibility thinking.
- Utilisation of the central Glaucoma Register across other related specialties/initiatives, i.e. Diabetic retinal screening, low vision patients, & macular degeneration.
- Assess the potential for Participating Optometrists to become specialists in glaucoma treatment including the possibility of providing initial assessments and medical therapy when legally appropriate.
Who are the key stakeholders and potential leaders in your scheme and why?
The key professional stakeholders of the scheme are the West of England Eye Unit (WEEU), East Devon Community Optometrists, Local Optometrist Committee (LOC), East Devon PCT, East Devon GPs, Social Services, Care Homes and IT Shared Services. All these stakeholders will be represented on the NECS Committee. Additionally, patients and local people are key stakeholders of the scheme and arrangements will be in place to ensure patient and public involvement in the scheme including representation on the NECS Committee.
The potential leaders in the scheme are:
- Dan Byles – Lead Ophthalmic Consultant, WEEU, Royal Devon & Exeter Hospital (RDE).
- Jim Faverty - Representing the LOC and Community Optometrists.
- Dr John Coop – Commissioning GP, East Devon PCT.
- Dr Sue Pocklington – Medical Director, East Devon PCT.
- Nicky Lavender – Modern Matron, WEEU, RDE.
- Jenny McNeill – Service Improvement Manager, East Devon PCT.
- Lily Chapman – General Manager, East Devon PCT.
- Mr Iain Tulley – Chief Executive, East Devon PCT.
- Angela Pedder – Chief Executive, Royal Devon & Exeter Hospital Trust (RDE).
These leaders have been identified as champions of the proposal. All are respected and influential within their fields. Some will be hands-on with the project, whilst others will be involved as part of the communications and spread strategy to bring about change and overcome any resistance within their respective organisations.
Proposed project management arrangements
The Project will be managed in a systematic manner, utilising PRINCE2 methodology:
- The Professional Executive Committee of the East Devon PCT will take the role of Project Board. They will have overall responsibility for the New Eye Care Service (NECS) and will provide direction, support and guidance to the project.
- A committee (Project Team) will oversee the management of the NECS, consisting of representatives of each stakeholder organisation involved with the NECS; West of England Eye Unit (WEEU), Optometrists, Local Optometrist Committee (LOC), East Devon PCT, Ea
- Day to day management of the NECS will be the responsibility of the NECSCO who will be employed by, or seconded to, the East Devon PCT and will act as Project Manager for the pilot, with dedicated time allocated for this role.
The project will be clearly focused in terms of aims, objectives and milestones. Progress will be monitored against expected plan and reported to the PEC, as part of the management and control of the project.
The project will establish Communications, Spread and Evaluation Strategies.
How will the success of the project be measured?
Establish an evaluation strategy which will include:
a) Regular monitoring against quantifiable measures such as:
- Release of 16.5% Ophthalmology OP Appointments at HES by the end of March 2005.
- Reduction in the follow up appointment delay at WEEU (presently 9 months) through the release of appointments at HES.
- Establish comprehensive Glaucoma Register for patients with stable glaucoma or ocular hypertension within East Devon by end March 2004.
- Establish optometric follow up clinics by June 2004.
- Establish Mobile Eye Care Unit (MECU) April 2005.
b) Monitoring of Qualitative measures such as:
Clinical audit of patients seen by optometrists compared to those patients seen by the WEEU to:
- Determine the clinical competence of POs compared to WEEU for glaucoma follow-up and monitoring.
- Establish the level of concordance of clinical opinion between optometrists and consultant – high level of concordance would signify success in clinical competency of optometrists.
- Determine if clinical transfer of glaucoma follow up patient care to community settings is acceptable.
- Care and decisions made by the PO will be audited with audit tool already used to monitor care transferred to HES.
(c) Evaluate the new IT system in terms of it being used to deliver a central register, the storage of patient records and monitoring system.
d) Patient and Staff Perception of the new service by means of surveys in terms of:
- Improved access
- Quality of Care
- Confidence in PO service
- Effectiveness of Central Register and NECSCO
e) Establish the cost effectiveness of the new service, by undertaking cost comparisons.
f) The final evaluation of the project will establish if this new patient care pathway is acceptable to be continued as a main stream and/or extended to neighbouring PCTs.
What are the challenges and barriers to the success of the project? How will these be overcome?
Clinical risk is breakdown in communication between PO, GP and consultant
Countermeasure: Planning and coordinating intra-professional communication and defined accountability is essential. This can be established with agreed Shared Care Protocols and monitored by direct referral feedback and audit.
Possible excessive follow up of suspect glaucoma patients who are really ‘normals’
Countermeasure: At clinical audit, analyse the length of time patients can be monitored without change to clinical findings before discharge from WEEU and releasing to community optometrists for normal eye examination schedule.
Under-utilised, ineffective and/or inefficient use of the mobile Unit MECU.
Countermeasure: Feasibility Study to be undertaken in Year 1 to establish demand and appropriate form of mobile unit. Use of MECU is to be coordinated by the NECSCO, which should lead to proper utilisation. Feedback and audit will also help.
Non-support of NECS by community optometrists for fear of losing patients to PO's practices
Countermeasure: Introduce PCT Workshop training sessions for all local Optometrists which will assist in awareness of benefits of new service. Proper patient education and inter-professional communication can prevent this.
Clinics already running at Axminster and Sidmouth may be affected by this proposal
Countermeasure: Retain and Extend existing clinics at Axminster & Sidmouth – run by a blended provision of nurse led and Participating Optometrists.
Central Register of Glaucoma patients does not currently exist – it may be difficult to establish from scratch.
Countermeasure: Set up working party to establish how this work can be taken forward – learn from the diabetic register.
Longer term vision of direct referrals to Optometrists may meet resistance from partner agencies
Countermeasure: Investigation should take place to establish the feasibility of opportunities for direct referrals, and what changes/training would need to take place etc.
The MECU service may not be cost effective
Countermeasure: Feasibility Study and Investigations to take place and comparisons made to comparable service such as accompanying by a nurse to a local PO.
PCT are responsible for ensuring calibration of equipment
Countermeasure: Optometrists to meet cost of maintenance. Optometrists to be accountable to ensuring calibration and maintenance is carried out by approved providers. PCT/Optometrist SLA to be established.
Current IT Infrastructure may inhibit successful implementation of proposed IT communication system
Countermeasure: Ensure Shared Services IT representation is on Project Team and all IT costs (initial and recurring) are included in proposal. Funding within proposal could actually lead to indirect improvements for Shared Services IT infrastructure.
Participating Optometrists will require NHS Connection
Countermeasure: Ensure relevant permissions are sought at very early stage of pilot.
NECS and MECU service is likely to increase current levels of referral in order to meet unmet need or by providing easier access
Countermeasure: Closely monitor referrals levels to both RDE and OP clinics. Undertake feasibility study for mobile unit and identify demand based on findings. Feasibility study will inform the scope of current unmet need.
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