Optimising the
Primary/Secondary Care
Interface in Eye care Services
Richard Best
Belfast Health and Social Care
Trust
Ophthalmology
Hospital Eye Service
One of the largest outpatient specialties in
NHS
 Rapidly evolving
 Changed from observation to intervention
 High volumes of patients
 Day case surgery

Ophthalmology
Accurate diagnosis
 Technological advances
 More treatments
 More patients

Pressures on Ophthalmology
More referrals
 Ageing population
 Chronic disease management-diabetes
COAG, ARMD
 Limited resources
(Staff/Equipment/Facilities)
 Guidelines informing practice (NICE)

NHS in UK
Change in last 10 years
Large increase in funding (6%GDP to
11%GDP)
 Macromanagement tools (access targets)
 Targets have become standards
 ? Sustainable

Current Problems
Demand exceeds supply
 10% rise in number of referrals
 Heavy use of IS to increase provision
 Financial constraints

Solutions
Increase funding/increased provision
 Waiting lists
 Effective use of resources
 Look at current model – is it appropriate?

Increased Funding/Provision
Outpatient waiting lists behave as a
complex system that resists change
 Appear self regulating ‘power laws’
 Obey their own laws
 Similar to traffic jams/avalanches


Shorten waiting lists increase referrals
Smethurst et al Nature 2001
Ideal Model
Patient Flow
Tertiary Care
Secondary Care
Primary Care
General Population
Actual Model
in Ophthalmology
Tertiary Care
Secondary Care
Primary Care
Population
Primary Care
GPs
 ‘Gatekeepers’
 Triage and assessment
 Provide appropriate treatment

Primary Care in Ophthalmology
GPs
 Undergraduate training
 GPWSi s (postgraduate training)
 Allied Health Professionals
 Ophthalmologists

Primary Care in Ophthalmology
Embrace skills of those working in primary
care settings
 Decentralisation of heavily populated
central units
 Allow recruitment of flexible practitioners
to practice in Primary care setting but with
strong links to the centre

Primary Care in Ophthalmology
Refinement of referrals
 Referral guidelines (Local development)
 Shared Care for chronic conditions
 Managed Clinical Networks

Primary Care in Ophthalmology
Referrals

Good referral should ensure that the right
patient accesses the right service or
specialist at the right time
Interventions to Improve Quality of
Referrals
Triage
 Referral guidelines
 Active educational input from local
secondary care specialists
 Structured referral sheets

Shared Care
Post op reviews
 Chronic diseases
 Telemedicine
 Combined clinics (specialist and primary
care team)

Managed Clinical Networks

Linked groups of health professionals from
primary secondary and tertiary care
working in a coordinated manner
unconstrained by professional and
organisational boundaries
Thank you