Enhanced eye care in Wales –
A new service
• What service do we want?
• How did we get there?
• How do we ensure it is fit for purpose?
What service do we want?
• Appropriate, efficient, fit for purpose
community eye care service for patients in
Wales
• Accessible for those who need it
• Learn from previous eye care services
– Updating and improving for patients
How did we get there?
Started with WECI
Welsh Eye Care Initiative (WECI)
• Welsh Eye Health Examination (WEHE)
• Primary Eyecare Acute Referral Scheme
(PEARS)
• Welsh Low Vision Service (WLVS)
Purpose of WECI
• Detect eye problems in individuals at high
risk
• Enable early assessment of acute eye
problems
• Provide an accessible low vision service
Perceived advantages
• Providing services close to peoples’ homes
• Reduced demand on GP and hospital resources
• More patients managed in primary care
• Better quality of referral from primary to secondary
care
• Using facilities and personnel which were underutilised
WEHE
The Welsh Eye Health Examination
• An extended eye health examination
• For those who
– have an increased risk of sight-threatening eye
disease
– would find losing their sight particularly difficult
• Patients may self-refer, or be referred by their GP
The Welsh Eye Health
Examination - WEHE
• Uniocular patients
• Patients who are profoundly deaf –need sight to lip read
• Patients with retinitis pigmentosa
• Patients whose family origins are Black African, Black
Caribbean, Indian, Pakistani or Bangladeshi
• Those at risk of eye disease by other reasons of race or
family history
Black and Minority Ethnic groups
Increased risk of sight-threatening eye disease:
Condition
Odds Ratio
Diabetic Retinopathy
2.96 Blacks vs Whites
Chronic Open Angle
Glaucoma
5.0 Blacks vs whites
Cataract
5.25 Asians vs whites
PEARS
The Primary Eyecare Acute Referral Scheme
•
Anyone with an eye condition that needs
urgent attention
•
Patients can self-refer
•
An appointment within 24 hours
Training and accreditation
• Optometrists must have specified equipment
in their practices
• Optometrists did theory training and were
assessed
• Approximately 90% of all optometrists in
Wales are accredited
Assessments
What optometrists learned
Increased use of a Volk lens and/or dilating
a patient (23.4%)
Increased confidence dealing with cases of
ocular pathology (17.7%)
27.5% described the experience as
‘traumatic’
WEHE & PEARS Service
Evaluation
Evaluation
• An evaluation was carried out
• Customised records cards were filled in by
optometrists
• Referrals scrutinised
WEHE & PEARS evaluation
• 6,432 record cards were reviewed
• 66% of patients were managed in practice (i.e.
not requiring GP or Hospital visit)
• 99% appropriate referrals by optometrists
• 100% patients satisfied
Sheen NJL et al. Novel optometrist-led all Wales primary eye-care services: evaluation of
a prospective case series Br J Ophthalmol 2009;93:435-438
Welsh Low Vision Service
(WLVS)
WLVS
Welsh Low Vision Service
• A rehabilitation service for people with a visual
impairment
• Based in 185 optometry practices
• Practitioners accredited by Cardiff University
• Anyone can refer including patients themselves
Welsh Low Vision
Service
A range of low vision aids
Welsh Low Vision Service Holistic
•Multi-disciplinary sessions during
training
•Training for rehabilitation workers
and specialist teachers
Just as effective as the hospital service
Comparing hospital and community low vision services
•No significant difference in clinical outcomes
•No significant differences in user centred outcomes
•Disability significantly reduced after low vision service
•Improved access
Court H et al. British Journal of Ophthalmology 2010
Proven services that are effective
•Low Vision
•PEARS/ WEHE
Why change?
Changes to PEARS/ WEHE needed
• There are categories of patients at risk of
eye disease that were not covered
• Ethnicity categories not well defined
• PEARS/ WEHE/ WECI can be confusing
• No permanency to services
Changes to PEARS/ WEHE needed
• Clinical guidelines had changed
• Focus On Ophthalmology
• Potential to alleviate hospital eye service
capacity issues
What has changed
• Updated
– Name of services
– Structure – further categories
– Clinical guidelines
– Referral forms
– Service guidelines
Name of services
• Welsh Eyecare Initiative now becomes
Wales Eye Care Service (WECS)
• PEARS/ WEHE are now amalgamated to single service
Eye Health Examinations Wales (EHEW)
• Welsh Low Vision Service now becomes
Low Vision Service Wales
Eye Health Examination Wales
(EHEW)
• Introduces new categories for:
– referral by DRSSW
– monitoring dry AMD yearly
– cataract referral refinement
Eye Health Examination Wales
(EHEW)
• Other improvements:
– Reporting of ethnicity and clarification of
ethnicity categories
– ONS Census linked
Eye Health Examination Wales
(EHEW)
• Guidelines for referrals, emphasis on:
– Optoms to repeat Intra-ocular pressure
readings with Applanation tonometry
– Optoms to repeat visual field examinations
Clinical guidelines
AMD monitoring - Dry AMD
•Advice about lifestyle and what
to do if sudden drop in vision etc
Cataract – Referral refinement
•Guidance about discussing with
the patient and a questionnaire
for the patient to complete
Referral and report forms
• New referral to ophthalmology form
– Paper and electronic
• New report to GP form
– Paper and electronic
Referral form
Report to GP
EHEW
How do we ensure it stays fit for
purpose?
Evaluation and Audit
• Service guidelines and new forms make it easier
• Regular audit
• Evaluation of referrals
• Findings from audits will feed into training
Training
• Benefits gained should outweigh cost
• Training programmes should focus on evidence
based practise and should always display strong
links to desired outcomes (Mays 2004)
• We need to ensure it has an positive effect on
behavior
Training – peer review
• Peer review as a vehicle for communicating
results of audits and changes to service
• Cases used to embed learning outcomes for
optometrist practitioners
• Discussing cases makes it ‘real’
• Evaluate impact that peer review has
Service review
Service
evaluation
Put new
structure in
place
Review
impact of
training
Areas for
improvement
Training –
learning
outcomes
linked to
improvement
areas
Conclusions
• We seek to have the best service possible for those
patients who need it most
• We will continue to evolve the service by evidence based
evaluation and training
• We believe that we have a service that will be fit for
purpose
Ensuring changes are communicated
• GPs
• Ophthalmologists
• Third sector organizations
• Other healthcare workers
• Patients!
Without whom..
• WG- Richard Roberts & Sarah O’Sullivan-Adams
• OW – Sali Davis & Mike George
• WOC – Ian Jones & committee
• WOPEC – Barbara Ryan
• Optometrists in Wales
Thank you
Questions?