The advantages of community eyecare pathways

In January Rob Webster, the chief executive at Leeds Healthcare Trust, made a rallying cry for community care, arguing it should be the NHS’s first option.

‘Getting to a large, out of town hospital can be daunting. Visiting a familiar opticians’ outlet is likely to be less off-putting’

Community-based diagnosis and care can and does save money. It adds value to GP practices and is a huge benefit to patients who would otherwise have to be assessed and treated in hospital.

Eye health is a prime example where commissioners are beginning to see the benefits. Across England more community-based eye health pathways are being developed, trialled and commissioned.

In most cases these new pathways are saving commissioners significant amounts of money. And in all cases they are providing better options for patients across a range of eye health problems.

A series of pathways, which cover the gamut of eye problems, have been developed by the Local Optical Committee Support Unit. As the name suggests, LOCSU is a support organisation for local optical committees across England. It helps community optometrists and opticians work together with local commissioners to design and add value to local eye health pathways, making services accessible for patients and cost-effective for the NHS.

Patients are diagnosed and often treated by community-based optometrists and ophthalmic specialists, situated in local opticians’ clinics on the high street and in the town centre.

Local treatment

In many cases, patients can self-refer − stepping in off the street, presenting eye problems that can sometimes be sorted without the need to go through a lengthy GP-to-hospital referral process.

GPs can also refer, of course. But in any event patients are diagnosed and can be treated locally without the need to travel to hospital. This is a key advantage, especially in the case of older, frail and vulnerable patients and for patients with low vision.

Getting to, and negotiating, a large, out of town hospital can be daunting. Visiting a familiar, small and friendly opticians’ outlet is likely to be less off-putting and patients are more likely to get a speedier assessment at a time convenient to them. 

One pathway is being trialled in East Riding of Yorkshire and Hull primary care trusts. Known as the Community Ophthalmic Referral Refinement Service, it is like a sophisticated first aid service for eyes.

Developed by the local optical committee, supported by LOCSU, it deals with a range of conditions and complaints, including red eye and blurred vision.

High patient satisfaction

Patients experiencing eye problems can walk straight into participating optical specialists, on the high street, without an appointment. This is also a benefit to general practice surgeries where there is no eye specialist GP, because the doctor can add value to the patient’s treatment simply by directing them to a local optometrist. The GP remains part of the care package.

A similar pathway is running in Sheffield, known as the Primary Eyecare Acute Referrals Scheme. Under the aegis of clinical director Dr Richard Oliver, Sheffield CCG has become a pioneer partner for the Sheffield LOC, backed by LOCSU.

Dr Oliver estimates the partnership will save an estimated £400,000 a year, improve outcomes and benefit patients. According to him, patient satisfaction is high.

Sheffield CCG has successfully developed a series of new enhanced services with Sheffield LOC and support from LOCSU.

These new pathways are:

• Cataract screening
• PEARS
• Glaucoma Referral Refinement/Contact Applanation Tonometry Scheme

According to Dr Oliver, who has been a GP partner in Ecclesfield since 1989, these new eyecare pathways place emphasis on “service change, not service cuts − efficiency not deficiency”.

Win-win situation

PEARS can accommodate patients presenting with flashes, floaters, visual blur, irritable eye and non-emergency red eye conditions.

‘Dr Richard Oliver argues that if the community schemes did not exist the total bill would have been £400,000 higher’

All patients with GOS 18 referral forms are triaged by experienced optometrists at a single point of access. Patients with suitable problems are then diverted for community management and are offered a choice of time and venue for their appointment.

The GRR/CAT scheme, delivered by optometrists using contact tonometers, is reducing the number of false-positive referrals for raised intraocular pressure. This takes pressure off hospital-based eye services that would otherwise be doubling up on unnecessary diagnostic interventions.

Filtering out false positive referrals before they reach hospital saves money − and reduces waiting times for patients who do need hospital eye services.

The cataract screening pathway is delivering a uniform approach to detection and referral for cataracts.

The Sheffield CCG-LOC partnership is a win-win solution for GPs, patients and the tax payer. GPs can refer patients with a whole raft of primary eye care problems directly to local opticians and optometrists. It provides a uniform, high-quality service and will reduce the number of false-positives for glaucoma diagnoses.

Meaningful choice

Dr Oliver argues that if the community schemes did not exist and all of these patients had been seen in secondary care then the total bill would have been around £400,000 higher.

‘GPs must think of this as their service to their patients. They remain in control’

Sheffield CCG also intends to introduce other community-based solutions with the LOC, including monitoring of stable ocular hypertension, provision of a low vision service and improved lines of communication with all letters from hospitals to GPs to be copied in to optometrists.

However, it is important to say that these pathways are not about choice in the abstract. Choice has to be meaningful. Having a choice of two bad things is no choice at all, while having only one option is all you need if the service is a perfect for you.

But the reality is GPs cannot cover every primary healthcare need perfectly and LOCSU believes contracting some specialist services to experts is a good thing − it is an extension of the GP’s surgery, not a rival to it.

Genuine success

The key thing is to get the relationship right − to create a relationship of genuine partnership and mutual support. We know this can work, because we have seen in the case of eye health that choice is already leading to real benefits for all − including GPs. The GPs who have created partnerships with our members are reporting genuine successes.

The “any qualified provider” process can be the key in terms of providing the mechanism to enable a CCG to commission these kinds of services. 

For example, in Cheshire the local optical committee was AQP approved in December 2012, becoming the second LOC to successfully complete AQP procurement. 

Cheshire Local Optical Committee did this by using a local optical committee single provider company set up by LOCSU.  The company, Primary Eyecare (Cheshire), has been awarded AQP status by Vale Royal and South Cheshire CCGs for the provision of a community ocular hypertension monitoring service. The new service is expected to see approximately 1,000 patients a year in optical practices who would previously have been monitored in secondary care.

In October 2012, Primary Eyecare (Stockport) achieved AQP status, which will allow practices in the Stockport LOC area to provide a minor eye conditions service.

On their doorstep

Since Stockport PCT introduced the LOCSU IOP (intraocular pressure) Referral Refinement Pathway in 2010, 77% of patients who would otherwise have been referred to secondary care for raised pressure have been looked after in primary care.

Prioritising case loads in this way means secondary care services can reduce waiting times and place focus on facilitating the most critical of cases. Efficient patient referral will also save money, with NHS Stockport projecting savings of around £60,000 a year for this specific pathway.

Community-based eye specialists − optometrists and ophthalmic specialists − have equipment that is uncommon in GP surgeries. They are also able to see patients quickly. They can deal with problems that may clog up GP clinics − conjunctivitis, minor eye injuries, blurred vision and the like.

They have specialist equipment too, which allows them to diagnose the risk of disorders such as glaucoma, effectively and efficiently − affording a higher deflection rate.

There is concern in some quarters that the “patient choice” epithet is merely privatisation by another name. This is wrong. The fundamental difference is the point of delivery, nothing more. It’s on the patient’s doorstep.

GPs must think of this as their service to their patients. They remain in control. Local optical committees merely deliver the service, through their members, on behalf of GPs.

Katrina Venerus is managing director at the Local Optical Committee Support Unit and an optometrist