Making prudent healthcare happen

A clearer vision – better eye health outcomes through prudent practise

  • Jill Paterson, Deputy Director of Primary Care, Community, Mental Health & Long Term Care , Hywel Dda University Health Board 
  • David O'Sullivan, Optometric Adviser, Hywel Dda University Health Board 
  • Bryan Beardsworth, Assistant Head of Primary Care and Dental Services, Hywel Dda University Health Board 
  • Donna Thomas, Low Vision Service Wales Manager
  • Sali Davis Chief  Executive, Optometry Wales 
  • Huw Bellamy, Chairman, South West Wales Regional Optical Committee 

Wales is making good progress in eye healthcare. While there is more to be done, the overall trend is one of improvement.  Our Together for Health:  Eye Health Care Delivery Plan [1] sets out a clear forward agenda about what we are doing, working in partnership across Wales.

The aims of prudent healthcare are such that in order to achieve them, a wide-reaching, comprehensive approach across a range of services is needed, which will result in the delivery of timely, safe care to patients of the highest quality.

As with the majority of healthcare services, there is no average patient. As such, services need to be adaptable but at the same time demonstrate clear processes; they need to be personal but withstand increased patient need and demand.

Even the best risk mitigation cannot override the old adage of only being as good or as strong as the weakest link. In terms of delivering eye care, there are a significant numbers of links and interfaces between services which need to be considered in order to provide a seamless service for patients which operates in the most safe and efficient way possible.

During the development of services, communication and collaboration are essential in order to ensure that even the best of service innovation or continued improvement is given the opportunity to come to fruition. To achieve our goals we must further develop patient pathways that are simple, yet effective and allow for patients and healthcare colleagues – sometimes  with limited insight into the overall service opportunities – an efficient and effective way to provide safe and effective  treatment for patients.

Best outcomes are achieved through primary and secondary care services working together to meet the needs of our patient. Based on the principles of prudent healthcare, we are continuing to develop optometry services so that care, which was once seen as the preserve of specialist hospital services, can now be routinely provided in local communities.

Image copyright: © Paul Boxley

Who is involved?

There are a large number of stakeholders involved in the development and improvement of any healthcare service. The main professionals working in collaboration to provide high quality and accessible eye care services include:

  • Dispensing opticians, who advise on, fit and supply spectacles and contact lenses, taking into account a patient’s lifestyle and vocational needs;
  • Ophthalmologists who specialise in eye disease, treatment and surgery. Medically qualified, they mainly work in eye hospitals and hospital eye departments;
  • Optometrists are specialiststrained to detect defects in vision, signs of injury, ocular disease or abnormality and problems with general health. They mainly work in the community offering advice and management of conditions, they can also make referrals when specialist advice or treatment is required.
  • Orthoptists work with ophthalmologists in hospitals and in the community and mainly deal with conditions relating to eye movements and the inability of the eyes to work together and glaucoma management.

These professionals are now working more closely together to embed the principles of prudent healthcare in eye care services to improve care for patients and make services more accessible. The only do what only you can do principle has been prevalent throughout all service developments, with the collective aim of ensuring patients are seen by appropriately-qualified clinicians.

Making it happen – What are eye care services doing to make prudent healthcare a reality?

The wider role of the optometrist and skill mix – ensure all professions are working at the top of their competency and specialist advice is only sought in appropriate cases.

Moving activity out of hospitals into primary and community locations to increase access to hospital eye services for patients with more serious conditions and to make services as locally available as possible.

Patient ownership and understanding – ensuring patients have a full understanding of diagnosis, treatments, management of conditions and impacts of lifestyle choices. This is an important part of ensuring they are empowered to achieve the best possible outcomes.

IT connectivity – ensuring all primary care services are linked to hospital services to allow quick and efficient referral routes to develop and to allow information to be shared by clinicians within the community and hospital settings.

New patient pathways – ensuring new treatments and recently developed treatments are not absorbed by historic methods of patient access.

Although there is still some way to go, these improvements have resulted in the development of a skill mix which enables patients to access a wide range of services from community-based settings, resulting in reduced demand on hospital eye care services.

The wider role of the optometrist and skill mix 

Historically, patient entry into eye care services has been via GP referral, community pharmacy or accident and emergency. Regrettably, none of these have been able to offer specialist input at an early stage, which can cause delays for patients in accessing care.

Signposting patients correctly at the very first opportunity, is an essential part of delivering efficient and effective services, which minimises waste. Specialist input at an early stage also ensures that only those people with appropriate need are referred into under-pressure services, resulting in a reduction in demand and lower waiting times.

Hospital eye care services have traditionally come under significant pressure, while a potentially supportive workforce in the community and primary care has been under used. The challenge has been to integrate the individual professions, resulting in increased effectiveness.

The Welsh Eye Care Service [2] was introduced in 2013, and provided a further enhanced remit for optometrists in primary care, that originally formed by the Welsh eye care initiative in the 2000s. It provides a free-at-the-point-of-access, in depth eye examination by a community based optometrist.  Following assessment by an appropriately-skilled clinician, the service has enabled more patients to be managed in primary care and ensures only those patients who genuinely need further specialist opinion, care and treatment are referred to a hospital ophthalmology department.

The service provides a menu of national enhanced services which are available locally, positively bringing care closer to the home of patients. Eligible patients are those with an acute eye problem needing urgent attention or those at increased risk of eye disease or who would find losing their sight particularly difficult.

Patients may self refer or be referred by a doctor, pharmacist or allied healthcare professional.  When patients present with an acute eye problem, optometrists will assess them within 24 hours.  A non-exhaustive list of patients also eligible for Welsh Eye Care Service examinations are those with profound hearing impairment, patients with sight in only one eye and patients with dry macular degeneration who attend for yearly monitoring.

A Welsh Eye Care Service examination is available for people from Asian or Black/African/Caribbean backgrounds who have a higher risk of sight-threatening eye diseases such as diabetes and glaucoma.

The wider role of optometrists and the Welsh Eye Care Service continues to evolve and in 2015 optometrists and dispensing opticians will be able to refer patients to smoking cessation services.

Expansion of the Welsh Eye Care Service is planned, schemes being piloted include optometry-based triage of new referrals to hospital eye services and follow-up appointments.  More information about the Welsh Eye Care Service is available at http://www.eyecare.wales.nhs.uk.

The Low Vision Service Wales [3] is part the Welsh Eye Care Service, and is a rehabilitation service for both adults and children with impaired vision. It is hosted centrally by Hywel Dda University Health Board. Before 2004, people in Wales with impaired vision could find themselves needing to travel substantial distances, and often waiting six to 18 months for a hospital appointment for NHS help with their low vision needs.

Impaired vision or deteriorating sight can cause or contribute to a number of significant problems for those affected including:

  • Medicine mismanagement
  • Loss of independence and depression
  • An inability to cook/clean/shop
  • Increased risks of falls, burns or malnutrition
  • Problems with education/employment/travel

It was recognised that with a little extra training, high street optometrists and dispensing opticians could be accredited to deliver a specialist visual rehabilitation service to those with impaired vision in their own local community.  This free-at-the-point-of-delivery NHS service is now offered out of approximately 190 high street optometrists/opticians practices in Wales and, as of April 2014, the service has seen more than 28,000 individual patients.

The Low Vision Service accredited optometrist or dispensing optician will:

  1. Offer up to an hour-long specialist low vision assessment within the patient’s own community, usually within two weeks;
  2. Trial, prescribe and dispense from a wide range of low vision aids, including electronic and manual magnifiers, lamps and some non optical devices (completely free of charge);
  3. Provide in depth information and advice on the individual’s eye condition/s, and their management;
  4. Offer referrals to other health and social care professionals, education and employment services as required;
  5. Advise and signpost to local resources, support groups and services;
  6. Provide replacements for lost or broken low vision aids as well as upgrading and recycling current aids as and when patient circumstances change;

The service is primarily designed to help equip patients and their families with the knowledge, tools support and resources to:

  • Better understand and manage their own eye condition/s;
  • Help reach their own achievable visual goals/aspirations;
  • Gain better awareness of, and access to, further help and voluntary support available in the community.

The Low Vision Service Wales also works very closely with social services throughout Wales in the form of rehabilitation officers for the visually impaired (ROVIs). They provide support with daily living skills, access to socialisation, befriending and support services, making grant applications, communication and linking in with other agencies including the NHS and societies.

Moving activity out of hospitals

Providing care in a community setting often gives a clinician more time to develop a relationship with their patients, especially in cases where they are monitoring conditions and treatments. Co-production between the patient and clinician will be better achieved in a environment in which the patient is comfortable and has time to build a relationship with the clinician.

Ophthalmic diagnostic treatment centres (ODTCs) are being developed across Wales and will develop a more patient-centred service using a multi-disciplinary team led by a consultant ophthalmologist and including optometrists, ophthalmic nurses, orthoptists, medical photographers and technicians.

Using electronic patient records will enable conditions such as glaucoma to be monitored within an ODTC. Patients can be seen in locations convenient to them by the multidisciplinary team, while the consultant ophthalmologist is able to review the clinical notes virtually. This will free up valuable clinic time within the hospital services while making use of the skill set across a number of professions and ensuring patients are seen in the appropriate location by the appropriate team.

Patient ownership and understanding

Eye care liaison officers are now based in hospital ophthalmology departments to offer patients advice, emotional support and information about eye conditions, benefits people may be entitled to, employment issues, useful organisations and contacts, registering sight loss and rehabilitation. By ensuring people newly-diagnosed with sight loss have access to information and support, these officers help to mitigate some of the negative impacts associated with sight loss, including poor mental health, increased risk of falls and loss of independence.

Information displays in patient waiting rooms have been found to stimulate patient interest and engage the patient, these appear to achieve success when medical information is presented in patient friendly language.  For example, fun facts that your eyes can detect about 10 million different colours, or that all newborn babies are colour blind and can’t produce tears until they are about six weeks old and if the human eye was a digital camera it would have 576 megapixels.

IT connectivity

In 2015, optometric practices across Wales will, for the first time, be connected to the wider NHS electronic infrastructure. This will allow optometrists to make electronic referrals to the hospital eye service.

The further development of electronic patient records will allow the two-way flow of clinical information between primary and secondary care and will streamline the management of patients with eye disease.

New patient pathways

Although the eye is a small organ, it is very complex and within our hospitals there are teams of specially-trained eye care professionals who provide treatment for diseases and problems that can affect each part of the eye. Ophthalmologists, ophthalmic nurses, orthoptists, medical photographers, and technicians provide specialist services for conditions including:

  • glaucoma
  • cataract
  • medical retina, including age-related macular degeneration (AMD)
  • uveitis (inflammation of the middle layer of the eye)
  • vitreo-retinal (problem with the back of the eye)
  • oculoplastics (relating to the eyelids)
  • cornea and anterior segment ( relating to the front of the eye)
  • retinal and YAG laser (additional eye procedure)
  • paediatric and strabismus (squints or cross eyes)

The number of people certified as having a visual impairment in Wales has reduced over the last five years falling from 1,737 in the year April 2008 to March 2009 to 1,362 in the year April 2012 to March 2013. This reduction in visual impairment in Wales is in part a result of new treatments such as that for wet age-related macular degeneration (AMD). In 2007, there was no treatment available for wet AMD. Last year (2013-14) almost 15,000 such treatments were undertaken in the hospital eye service which prevent sight loss.

Cataract surgery remains the most common surgical procedure in Wales and to further streamline the journey for patients optometrists are becoming involved in assessment before and after patients operations. This releases pressure on hospital eye services and allows patients to receive a significant part of their care close to home in a convenient community setting.

The Diabetic Retinopathy Screening Service for Wales (DRSSW) is a free service established for all eligible people registered with diabetes in Wales to reduce the risk of vision loss due to diabetic retinopathy. Diabetic retinopathy is a complication of the eye that can affect anyone who has diabetes, regardless of the type or treatment, causing damage to the blood vessels supplying the retina – the seeing part of the eye.

Diabetic retinopathy generally has no obvious symptoms until it is advanced so early detection is essential. If you are diagnosed with diabetes, you will be referred by your GP and should receive an invitation to attend screening within three months of being placed on the DRSSW register.

Retinal screening is a straightforward procedure that should take approximately 40 minutes. Photographs of the retina are taken using a specialist camera and then forwarded to a team of retinal graders who look for signs of diabetic retinopathy. On completion, results are then sent to the patient and GP.

Conclusion

The changes in progress for eye care in Wales are the most significant for a generation. Vital to delivery of a prudent healthcare approach is ensuring that those who deliver eye care, whether in optometry or ophthalmology are equipped to embrace the changes and meet the challenges this new exposure for eye care will bring.

Successful execution of the concept of prudent healthcare will be demonstrated in relation to ophthalmic care in a greater number of the patient population accessing sight tests, if the numbers of those accessing sight tests increase this will ensure that preventable sight loss is detected, diagnosed and treated earlier.  For those who already have sight threatening conditions we believe that services such as DRSSW and the Wales Eye Care Service will help ensure that the patient is treated in the right place at the right time, successful triage in primary care will enable secondary care colleagues to manage the care of that patient in a timely and efficient manner.

The key actions that will be addressed are as follows:

  1. Education of primary eye care professionals e.g optometrists, dispensing opticians about the concept of prudent healthcare so that in turn patients can assume responsibility for regular sight tests (in most circumstances every two years)
  1. Education of secondary care eye health professionals about the Wales Eye Care Service and the conditions that can be managed in a primary care, community based setting
  1. Clear pathways into secondary care to ensure that the patient’s care is delivered by the appropriate personnel
  1. Full utilisation of the Wales Eye Care Service to ensure that patients are not accessing secondary care services when they could be seen in primary care
  1. A public health campaign that will raise awareness of high street, community based services

The new Wales Eye Care Service which fits the principles of prudent healthcare will expect improved outcomes and better value from optometrists and consultants in secondary care and we must be prepared to review the service and to look at how the service may be extended to fully utilise the skills of these eye care professionals.  By prudent healthcare we mean healthcare which is conceived, managed and delivered in a cautious and wise way characterised by forethought, vigilance and careful budgeting which achieves tangible benefits and quality outcomes for patients.


 References

  1. Welsh Government – Together for Health: Eye Health Care – http://www.wales.nhs.uk/documents/Eye-Health-Care-Delivery-Plan-Wales-e.pdf
  2. Wales Eye Care Service – http://www.eyecare.wales.nhs.uk.
  3. Low Vision Service Wales – http://www.eyecare.wales.nhs.uk/low-vision-service-wales

Further reading

Open Eyes Project – http://www.wales.nhs.uk/nwis/integrated-eye-care-for-wales

Visual Impairment – http://wales.gov.uk/newsroom/healthandsocialcare/2014/visual-impairment/?lang=en

New Patient Pathways – Vaughan Gething (Deputy Minister for Health) – http://wales.gov.uk/about/cabinet/cabinetstatements/2014/eyecare/?lang=en


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