Peterborough: Glaucoma Pilot
Aim of your project
There is currently no structured system of screening for Glaucoma, within the Peterborough Health Economy. The aim of the project is to set up a new and radical system for suspected or diagnosed glaucoma patients, it will transfer the screening and monitoring of selected high risk patients and those with stable glaucoma from the hospital to the community. Patients with unstable disease or those who do not meet the strict exclusion criteria will be seen in the acute trust by an Ophthalmic Consultant.
What organisations will be involved in and supporting this application? Why do you believe they are crucial to your proposal?
The following organisations will be involved in and supporting our application:
- Norfolk, Suffolk and Cambridgeshire Strategic Health Authority (NSC) – support from NSC has been given and will be required to advise on and coordinate on any role changes which need discussion nationally.
- Greater Peterborough Primary Care Partnership (North and South Peterborough PCT, 75% of catchment population).
- South Lincolnshire Primary Care Trust (20% of catchment population).
- GP representatives will be identified by their respective PCT’s.
There is a strong and longstanding history of support from local Primary Care Trusts and GP’s for modernisation developments. Their support and guidance will be essential in the setting up of this new service to ensure that we meet the needs of patients in the Peterborough area and to facilitate the identification of patients at risk of developing Glaucoma.
- Peterborough Hospitals NHS Trust – support from the Trust Board and Ophthalmic Clinicians will be crucial in changing the delivery of care for the patients and ensuring sustainability.
Optometrists:
- John Avery, Specsavers Opticians, Peterborough
- Sheila Urquhart, Specsavers Opticians, Peterborough
- Carl Love, Optometrist, Yaxley
- Phillip Edwards, Ophthalmic Opticians, Market Deeping
- Christine Pirrie, Optometrist, Stamford
- Robert Whitehead, Optometrist, Whittlesey
- Chris Coakley, Coakley & Associates, Wisbech
We have developed excellent long term working relationships with the Optometrists supporting this application. This group were part of the project team responsible for developing and implementing our Direct Access Cataract service. Their role in developing the service will be crucial as they will play an active part in the redesigned service.
Objectives of the project - why do you want to be a Pilot Scheme?
In Peterborough we have a long track record of continual innovation and support for NHS colleagues. Our Direct Access Cataract service is recognised nationally. This scheme will provide a first class opportunity to continue our innovative work within Ophthalmology in developing a gold standard Glaucoma service.
Objectives of the project include:
- To provide a service focused on the needs of our patients and offering choice.
- To develop a community based Glaucoma screening service.
- To increase the skills of community based Optometrists in screening patients for Glaucoma.
- Transferring care into the community thereby releasing outpatient capacity.
- To develop a service which allows better management of the disease and timely appropriate treatment.
- To enable Optometrists to refer directly to the hospital.
- To take a proactive approach in managing the disease by providing a screening and monitoring service not currently offered to high risk patients.
Where to you want to be in 2 years' time? Describe your vision for delivery of Chronic Eye Disease Services
In Peterborough, joint working has resulted in the successful development of a community led Diabetic Retinopathy and Direct Access Cataract scheme.
These schemes further develop the skills of community based Optometrists through annual training sessions. The modernisation of Glaucoma services in Peterborough will compliment the work already undertaken to ensure that patients receive a first class service in all aspects of Ophthalmology. A principle role of Optometrists will be the recognition, measurement and interpretation of glaucoma. Optometrists will be comfortable in their abilities to monitor glaucoma following an intensive training programme and ongoing support.
The vision of Peterborough Hospitals and its community partners is that patient attendance at an Acute Unit should only take place when necessary, and wherever possible services be provided in the community. This in turn relieves pressure on outpatient clinics enabling advanced access for complex patients. This vision applies not only to Chronic Eye Disease Services but all specialities.
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?
Within Peterborough, we have identified 4 tiers of glaucoma patients as follows:
Tier 1 - General public, a percentage of whom will develop Glaucoma
Tier 2 - Glaucoma suspects with Occular Hypertension
Tier 3 - Patients controlled with eye drops
Tier 4 - Patients uncontrolled with eye drops
We want to pilot and implement the screening and monitoring of patients in tiers 1, 2, and 3 in the community by trained and accredited Optometrists. Patients whose condition deteriorates and falls within tier 4 will be referred by the Optometrist for Consultant Ophthalmologist input will be seen in the hospital until their condition is stabilised, where after they will be treated in the community.
Criteria will be established to determine what constitutes ‘stable’ patients to be treated in the community following Consultant Ophthalmologist intervention.
An audit of both the clinical and administrative processes will be undertaken for the full period of the pilot.
Documentation to support the process will be drawn up in consultation with our Patient Advice and Liaison Service (PALS), the International Glaucoma Association and Trusts patient’s forum. This will include:
- Patient information leaflet – promote education and awareness.
- Exclusion criteria to decide on suitable patients to be screened and monitored in the community.
- Jointly agreed protocols.
Part of the project will include the development of a database to facilitate sharing of information between all stakeholders and maintain accurate screening records. Electronic links between Optometrists and the hospital will be investigated as part of this project but consideration will be given to the requirements of the Electronic Booking programme.
A glaucoma co-ordinator will be seconded to co-ordinate the whole process and maintain a database record of patients who are part of the screening programme.
The pilot will involve working with the Peterborough Primary Care Partnership and other local PCT’s to facilitate earlier detection of the disease through the screening of high risk patients. This is a step forward from traditional screening programmes which treat patients already diagnosed with the disease.
Within Peterborough, Optometrists accreditation training sessions are held annually for our existing Diabetic Retinopathy and Direct Access Cataract schemes. Following an intensive period of initial training, including a period of time spent in clinic shadowing a Consultant, it is our intention that ongoing Glaucoma accreditation will be included within the current training plan.
All community optometrists will be offered the opportunity to apply to join the scheme and take part in training and gain accreditation.
Throughout the pilot and implementation of our community based glaucoma screening service, patients will be at the forefront. There will be patient representation on our project team and a full evaluation will be carried out via a patient satisfaction survey.
How can being a pilot help you to achieve your vision?
Our experience in implementing new clinical processes is that they are more successful when introduced in a carefully controlled trial and audit environment. This both reassures clinicians allowing adjustments to be made leading up to a full implementation. This is the principal adopted for all our projects and supported by the Trusts Clinical Management Board.
Inclusion in the pilot will compliment the work already undertaken with our Direct Access Cataract and Diabetic Retinopathy schemes, offering a more patient centred service. Linking in with other organisations and health economies involved in the chronic eye disease pilots will allow us to share learning and use modernisation tools and techniques to redesign and develop patient pathways and services.
What are the short, medium and long term benefits?
Many of the benefits outlined below we would expect to become apparent in the short and medium term. With the development of the project being sustained, long term benefits would be realised.
a) Patients
- Reduction in waiting time for initial assessment.
- Easier and more convenient access to accredited Optometrists spread across the catchment area.
- Provides a multi-disciplinary Glaucoma service.
- Agreed date and time for all appointments in line with Access, Booking and Choice.
- Better education and awareness about Glaucoma.
- Improved detection of patients with Glaucoma as a result of increased clinical awareness.
- Sight loss prevention through earlier detection of the disease.
b) Staff
- Capitalises and builds on the existing skills of Optometrists
- Continued professional development and enhancement of specific skills in the management of Glaucoma patients (Via the Peterborough training programme) for Optometrists.
- Opportunity to gain clinical treatment skills through an accreditation scheme.
- Opportunity for junior doctors training, with increased exposure to unstable glaucoma patients where a change in management would be necessary.
- Opportunity for Consultants to share their clinical skills with other professionals.
c) Organisations/local health economy
- Release of outpatient appointments (estimated 4,000 per annum).
- Increased capacity within the hospital for Consultants to treat more complex cases.
- Continued partnership working and exposure to new ways of delivering care.
Who are the key stakeholders and potential leaders in your scheme and why?
- Patients: Within Peterborough, we have asked for interested members of the International Glaucoma Association to take part in our project discussions together with local patient representation.
- Clinicians: Need to ensure clinical leadership and ownership.
- Optometrists: Commitment from the Optometrists to participate and develop their skills. Sign up to delivery of the scheme.
- Primary Care Trusts: Support and funding needed to sustain the development and identification of patients with a high risk of developing Glaucoma.
- Local General Practitioners: For support and advice.
- Voluntary sector: The local group of the International Glaucoma Association have been invited to participate as expert patients.
- Trust Board: Support for development and sustainability needed throughout the pilot and rollout.
Proposed project management arrangements
We will follow a proven project management approach within Peterborough Hospitals. The project will be supported by a dedicated project manager who is part of the Trust Transformation Team and has worked with the Ophthalmology department for several years. A project team will be formed and will include representation from each of the key stakeholders, including patients, the voluntary sector and ophthalmic staff. The project team will be supported by a project steering group led by the Director of Operations and Organisational Development, Bill Stevenson. An accountant will be assigned to the project to advise and monitor expenditure.
Monthly meetings will be held for the duration of the project and monthly reports will be circulated to all lead organisations.
How will the success of the project be measured?
The success of the project will be measured using both qualitative and quantitative methods:
- The increase in the earlier detection of patients at risk of developing glaucoma will be monitored.
- The number of hospital outpatient appointments transferred to the Optometrist community led screening programme.
- Patient satisfaction. It is our intention that we will have patient representation on the project team from the start of the project. They will be involved in every stage of the process and take the lead on patient satisfaction surveys which will be und
- Optometrist enhanced skills. Following a period of Consultant led training, Optometrists will have to demonstrate they have met set competencies to become accredited. This will be repeated on a yearly basis.
- Optometrist and GP satisfaction. As with all Ophthalmic projects, GP’s and Optometrists will be represented on the project team and actively involved in redesigning the process. Their satisfaction will be measured at various stages of the redesign using
Objectives will be reviewed regularly throughout the project.
The Trusts Clinical Audit Department will be responsible for the audit and measurement of outcomes.
What are the challenges and barriers to the success of the project? How will these be overcome?
Sustainability
A dedicated project manager has been assigned to the project. The project manager is a member of the Transformation team, a group of professional project managers who are a dedicated change management team for the acute trust and health economy. These project managers introduce sustainable change in the way services are provided for patients using modernisation tools and techniques. The team have a track record of delivering successful and sustainable service redesign. A steering group and project team will meet regularly to monitor progress and deal with issues.
Optometrist buy-in
Over the last 7 years, partnership working has been established between Optometrists and the hospital through the setting up of a community led diabetic retinopathy and direct access cataract service. Expressions of interest have already been made from the Optometrists listed as part of our bid. Further expressions will be sought from all local Optometrists, including those involved our Direct Access Cataract and Diabetic Retinopathy schemes.
Consultant buy-in
Ophthalmology currently have a dedicated project manager who is part of the Trusts Transformation Team. They currently attend monthly Ophthalmology Clinical Management Team meetings to progress modernisation ideas, developments and gain consultant support.
Trust
During the development of our cataract and diabetic retinopathy schemes, trust was identified as a concern by the Ophthalmic Consultants who were cautious about the skills of the Optometrists. This was overcome through the development of training sessions and annual accreditation.
Training
An intensive training programme for community Optometrists will be designed and led by the Ophthalmic Consultants. Following initial training and accreditation, the ongoing training will be combined within our existing annual training session for Diabetic Retinopathy and Cataract which are also led by our Ophthalmic Consultants.
Administration support
A co-ordinator role will be developed to coordinate the process between primary, secondary and community care.
Prescribing issues
A member of our pharmacy team will work with and advise the project team on prescribing issues to enable Optometrists to treat glaucoma patients using jointly agreed protocols.
Communication is an essential element of any improvement or redesign work. Within PHT and throughout the health economy, robust communication mechanisms are already in place.
These include:
- Staff newsletters. Including ‘The Pulse’ (staff newspaper).
- Specialist newsletters e.g. GP Update.
- All websites (Intranet, Extranet, Internet).
- Meetings – Clinical, Managerial, including Trust Board, PCT Board and Modernisation Board.
- Local Media (have a keen interest in new developments).
- Clinical Governance and audit days.
These potential challenges and barriers are already familiar and plans have been developed to ensure they do not affect progress of the project. All professionals involved have expressed support and a keen interest to be involved. Regular project and steering group meetings will be held to communicate progress and offer opportunity for everyone to give feedback.
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