Waltham Forest: Low Vision Pilot

Aim of your project

To provide a local, community based, accessible service for patients requiring treatment for low visual acuity, glaucoma and macular degenerative diseases.

The service, based in three centres, will provide high quality treatments, advice, appropriate aids and lighting. The service will be made easily accessible using new referral pathways from any healthcare professional and will also include self-referral. For these three services there will be a fast referral, diagnosis and care pathway with appropriate treatment plans that will reduce patient waiting times, support the detection of early disease, reduce pressure on secondary services by offering diagnosis and treatment in three community settings.

To reduce the need for the patient to move between primary and secondary care these services will be provided by multi-disciplinary and multi-agency teams, using agreed shared care protocols. One-stop services will be provided for patients with LVAs, offering a holistic approach for aids and integrating working with various care teams a holistic network will be formed. This will be patient centred and offer informed choice. Waiting times will be reduced in both primary and secondary care - benefiting both patients and clinicians.

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

This proposal is a multidisciplinary, multi-agency development offering early diagnosis, simplified referral processes and a range of treatments including lifestyle change support.

Waltham Forest PCT, Whips Cross University hospital and the Local Joint Optometry and Ophthalmology Committee have been the initial drivers supporting this bid. The PCT and hospital will be responsible for commissioning the service, providing clinical and managerial expertise, ensuring revenue costs post pilot are picked up, provide an education and training framework around the disease areas.

User groups such as the diabetes network, RNIB etc have been involved in developing this pilot and were part of the group that formally approved the stage 2 bid. Users from existing groups such as the blind group and the diabetic service development group are members of the project steering group.

Various voluntary organisations such as Age Concern are involved. Social Services and the Hospital at Home Services are also involved and will be essential in promoting independent living and supporting health prevention initiatives that will reduce admissions to nursing homes or long term care.

The NSF Older People Care Team will be involved as many of the patients in this group will be over 65 and a holistic approach will be required.

Community optometrists and ophthalmologist are an integral part of the pilot development as this is a community-based development and patients will be treated in the community wherever possible to prevent unnecessary burden on acute services. Community optometrists will be involved to act as early triage and prevent unnecessary referrals.

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

Waltham Forest is an innovative PCT with a history of developing pioneering new models of service delivery, particularly around integrated care pathways from secondary to primary care and new service developments. Waltham Forest is developing services on a geographic ward cluster. Each cluster includes primary and secondary care, local authority and social services, voluntary and patient organisations where an integrated and collaborative approach is being fostered.

The overall aim of this pilot is to provide three local community centres of excellence offering accessible, rapid diagnosis and early referral, treatment and on going support. The emphasis will be on developing rapid efficient referral pathways and supporting patients by providing high quality treatment, care and advice. This pilot programme will be mainstreamed after completion and both the PCT and the acute trust have committed to meeting the revenue costs and continuing the service once the pilot period is ended.

The pilot will develop treatment and service models using the recommendations from the Eye Care Steering Group, resulting in the production of custom made services. The care pathways will be used and developed initially. The pilot process is exciting as it encourages and supports innovation and engenders an atmosphere of service improvement, building on the aspirations of local patients and clinicians. The pilot process encourages audit and user participation to improve working practices.

The pilot will also be used to remodel the workforce in this area, making sure we have the most effective use of staff and resources, ensuring that Waltham Forest provides a high quality working environment for staff who will be encouraged to participate and support this development, as well as for patients who will also be actively supported to participate in this service development. Pilots can also encourage growth of the workforce as has been well demonstrated by the Waltham Forest Action on Cataracts (AoC) and diabetic retinopathy service developments.

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

In 2 years’ time we want to have established three community based clinics that have well defined care pathways and are beacon centres of excellence. These centres will provide prompt access, on-site diagnosis, treatment and rapid referral to other parts of the service when required. We also want to develop a service where patients can self-refer and optometrists can directly refer to other services, including secondary care.

We want to develop a team of optometrists with special interests, initially three such optometrists will be trained for each of the clinical areas. The intention is that they will provide training and development for the rest of the community optometry service, having clear integration with acute services, social services, services at home and for voluntary organisations offering an efficient, well trained and co-ordinated joint ophthalmology / optometry service.

The service will be fully audited and the lessons learnt here on service design and managing capacity will be transferred to other areas. In two years’ time the service will have reduced waiting times in primary and secondary care and the optometrists with special interests will be acting as leaders for the optometric community.

The ophthalmologists will focus their expertise on providing care for those who need treatment faster, with reduced wait times, but they will also to have more time to deal with patients who require it. Through clinical governance the pilot will raise the standards of eye care in the community by providing accredited optometrists to share the care of the glaucoma patients.
Most importantly the pilot will raise the quality of the service for the patient.

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?

We want to confirm and establish four key principles:

1. By having highly trained staff in the community we can prevent unnecessary referrals to secondary/tertiary services. Previous study in Waltham Forest has already shown that if a patient receives appropriate information at the time of their initial diagnosis with options for their care, later non-attendance for more complex procedures is reduced significantly.

2. We want to develop and establish inter-professional referral pathways including self-referral. This has already been successfully done in Waltham Forest e.g. our diabetic service has referrals from optometry directly to podiatry. In each of the clinical areas we want to develop a direct booking service offering choice. This builds on the principles of the single assessment process and patient centred care where the patient is assessment is kept to a minimum.

3. We want to develop joint ophthalmology/optometry clinics in the community, providing a full range of services at one appointment, eg. BD8, information, diagnosis, LVAs, lighting, information and Social Service contact, etc. Once a patient enters the optometry community service they can easily and reliably be referred to where ever they need to be best treated.

4. We want to develop the optometrist service as a whole and encourage community optometrists to take part in wider initiatives such as smoking cessation, the national falls campaign and act as a central contact point where appropriate.

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

The pilot will provide the resources to allow us to explore this development. It will initially support the development by providing necessary equipment, workforce, IT, training and managerial support. The pilot will also, more importantly, provide the space and atmosphere for change. The two leading organisations in this pilot bid have both committed to mainstream the services once fully developed. This pilot if carefully managed will act as a spotlight to encourage our most innovative and leading clinicians.

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

a) Patients

Individual patients will receive a quality service that is fast, accessible and effective with inter-professional referrals where appropriate. Full information will be provided so that people can be supported to take responsibility for their own management.

In the medium to longer term, there will be a reduction in the number attendances to acute services, a reduction in DNAs and reduction in waiting times for other services and procedures. Patients will have greater choice by being able to self-refer and will have their needs assessed and demonstrated only once. Patients will be able to receive treatment at an earlier stage, eg. AMD, and receive continuing high quality care thereafter.

b) Staff

Staff will have opportunities to develop special interests and work within a closely integrated health care team. There will be a wide range of training opportunities, particularly working with secondary care and acting as specialist in their own right. Revised treatment and referral pathways will enable staff to work more productively particularly optimising the use of patient held medical records. With an integrated workforce and a focus being given to community optometry services, there will also be increased morale and reduced levels of stress.

In the longer term, new career options will be available in a redesigned workforce.

c) Organisations/local health economy

There will be greater efficiency in how services are accessed and utilised, resulting in reduced wasted appointments, better patient compliance, a reduced need for beds and physiotherapy after unnecessary falls.

With information and contact points being made widely available, patient satisfaction will be increased with a reduced complaints. It is also anticipated that there will be fewer referrals to mental health services for depression as often occurs with failing sight and inadequate information and support.

In the longer term, it is expected that the overall health and quality of life of the community will be improved.

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

Waltham Forest PCT

James Slater as PCT Director of Primary Care and Interface Services. This post has responsibility for developing primary care services and integrating primary and secondary care. It is intended to develop a seamless service for community optometry and this post holds financial, managerial and operational responsibility for this area. WFPCT have committed to revenue pick and mainstreaming the service after pilot period ends.

Roy Brackley, Optometric adviser and Heather Autteridge, PEC Member Eye Lead.

Whipps Cross University Hospital

The Consultants working in Optical Services at WXUH - H. Towler and S. Bryan will form an integral part of this service development, providing clinical expertise, training and support. As above, Whipps Cross Hospital has also committed to revenue pick up and support after the project ends.

Jon Findlay, director for Interface and Service Development will provide senior managerial support.

Local Optical Committee

The Local Optometric Committee fully supports this proposal and will provide support to the project in engagement with community optometrists, etc.

Chair B.D. Kaushall and the 8 Executive Members will be providing professional support to the pilot and will act as primary care clinical leaders.

Patient user group

A. Bhasin, Waltham Forest, is committed to ensuring that patients and carers are a fundamental element of service development. Only after consultation and agreement with users' groups have these plans been developed this far. All further development will involve appropriate user groups.

Care of the elderly

Carol Wilson is Director Lead. The majority of patients using these services will be elderly people. In order to ensure integrated services, particularly around referral pathways, it is essential older peoples services are an integral part of this pilot development.

Social Services

Carol Wilson, Joint Director Lead for Health and social Services. It is important to create an integrated, sustainable service, therefore the patients, commissioners and providers must be involved fully. This will lead to further continued development.

Proposed project management arrangements

There will be a Project Board consisting of:

There will be a wider project steering group consisting of:

Meetings will also be held 3 monthly with Optometrists with Special Interests (OwSIs) and 6 monthly with all community based optometrists who are accredited for fast track AMD referrals and who are involved in glaucoma shared care.

How will the success of the project be measured?

There are a number of success criteria the pilot will be seeking to achieve. Short to medium term success criteria are:

A robust database will be developed to ensure capture of all necessary data, patient details, dates of referrals, screening and treatment offered allowing access, activity and clinical outcomes to be monitored.

Longer-term success criteria would be measured by improvements in the overall eye health status of the population with reduction in number of people registered blind using primary care disease registers.

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

Ensuring there is sufficient funding to properly implement the scheme and train the workforce. This is being overcome by adopting a joint management approach between the PCT and acute trust taking financial responsibility for ensuring scheme is successful and mainstreamed. This has been highlighted through the LDP/Saff process.

Old fashioned barriers between professionals hindering successful implementation. Having joint clinical responsibility between primary and secondary care and developing leaders within the workforce to champion the pilot will overcome this.

Optometrist change of attitude to regard the patient holistically. This will be overcome by having a comprehensive training programme.

Identifying LVA patients, thereby establishing a register. This requires the help of all professionals and will be achieved through multi-disciplinary working.

Offering choice when booking appointments. A particular challenge will be to offer information that is understood, leaflets in larger print size, does not address the issue of the illiterate. This will be overcome by working closely with patient representatives, voluntary organisation and developing a buddy system when a friend/relative/carer is asked to attend the appointment.

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