Ophthalmology Scoping Exercise
Draft Report
CONTENTS
Page
2
1.
Abbreviations
2.
Introduction
3
3.
Health Needs
5
4.
4.1.
4.2.
4.3.
4.4.
4.5.
4.5.1.
4.5.2.
4.5.3.
4.5.4.
Current Position
Contracts and Providers Cost and Activity Profile
Referrals
Pathways
Casemix
Quality and Patient Experience:
Outpatient Cancellations and DNAs
Waiting times
Choose and Book Slot Availability
Local Needs and Priorities (includes NHS Choices,
Complaints, PALS)
4.5.5. Serious Untoward Incidents
4.5.6. Service Quality
4.6.
Patient Choice
4.7.
Incentives to Drive Up Performance
4.8.
Workforce
7
7
13
16
17
19
19
19
20
21
5.
5.1.
5.2.
Service Pressures
Diabetic Retinopathy Screening Service
New NICE Guidance for Glaucoma
29
30
31
6.
6.1.
6.2.
32
33
34
6.3.
Options Appraisal
Primary Eyecare Acute Referral Scheme (PEARS)
Glaucoma Referral Refinement and Ocular Hypertensive
Monitoring
Pre and Post Operative Cataract Service
7.
Recommendations and Next Steps
37
23
23
24
27
28
35
1
1. ABBREVIATIONS
AOP: Association of Optometrists
ARMD / AMD: Age-Related Macular Degeneration
CQC: Care Quality Commission
DNA: ‘Did Not Attend’
DRSS: Diabetic Retinopathy Screening Service
GAT: Goldmann Applanation Tonometry
HCC: Healthcare Commission
HRG: Health Resource Group
IOP: Intra Ocular Pressures
LES: Local Enhanced Service
LIS: Local Incentive Scheme
LTHT: Leeds Teaching Hospitals NHS Trust
MYHT: Mid Yorkshire Hospitals NHS Trust
NEHEM: National Eye Health Epidemiological Model
NICE: National Institute for Health and Clinical Excellence
NHS WD: NHS Wakefield District
OHT: Ocular Hypertension
OMP: Ophthalmic Medical Practitioner
OPDR: Ophthalmic Photographic Diabetic Review
PALS: Patient Advice and Liaison Service
PbR: Payment by Results
PCT: Primary Care Trust
PEARS: Primary Eyecare Acute Referral Scheme
PROMS: Patient Reported Outcome Measures
QOF: Quality Outcomes Framework
RTT: Referral to Treatment
SHA: Strategic Health Authority
SUS: Secondary Uses Service
YEH: Yorkshire Eye Hospital
WDCHS: Wakefield District Community Healthcare Services
WECI: Welsh Eye Care Initiative
WYCSA: West Yorkshire Central Services Agency
2
2. INTRODUCTION
National Context
The final report of the NHS Next Stage Review, High Quality Care for All, sets
out the strategic direction for driving improvements in the quality of care
across the health service, in particular, working in partnership to prevent ill
health, providing care that is personal, effective and safe. Our vision for
primary and community care draws together the main conclusions of the Next
Stage Review for community-based NHS services, including eye care
services, and sets out a strategy based around four key areas:
 Shaping services around people’s needs and views
 Promoting healthy lives and tackling health inequalities
 Continuously improving quality
 Ensuring that change is led locally
In January 2007, the Government announced the results of the General
Ophthalmic Services Review. The review concluded that there is a successful
sight testing service, which provides patients with convenience and choice
and that this should be built on. The review recognised the potential to
develop more accessible, tailored eye care services for patients by making
greater use of the skills that exist among eye care professionals who work in
primary and secondary care settings, to help diagnose and manage a range of
eye conditions. The review also saw scope for greater collaboration between
the NHS, social care and the third sector in providing integrated services for
patients with low vision problems.
Naturally, national work and policy will shape the direction of commissioning
of local services. The 18 week standard has particular significance for
ophthalmology services in Wakefield District.
The Operating Framework for the NHS in England 2009-101 sets out that from
1 January 2009, the minimum expectation of consultant-led elective services
will be that no one should wait more than 18 weeks from the time they are
referred to the start of their hospital treatment (unless it is clinically
appropriate to do so or they choose to wait longer).
From April 2010 minimum operational standards for Referral to Treatment
(RTT) of 90 per cent for admitted patients and 95 per cent for non-admitted
patients must be achieved across all specialties without exception.
In addition to the above it is also the expectation of Yorkshire and the Humber
Strategic Health Authority (SHA) that all PCTs within the region will further
improve RTT waiting times during 2009/10 with 90% of patients being treated
within 15 weeks and 50% of patients being treated within 8 weeks.
Local Context
Ophthalmology has historically been a pressured specialty in terms of
delivering waiting time targets at Mid Yorkshire Hospitals NHS Trust (MYHT),
the main secondary care provider for Wakefield District. Delivering against the
3
18 weeks standard is a key strategic objective for NHS Wakefield District
(NHS WD).
During negotiation of the 2009/10 MYHT contract significant variances
between PCT expected demand and MYHT expected capacity were identified.
Furthermore, it is expected that the new National Institute for Health and
Clinical Excellence (NICE) guidance on Glaucoma and Ocular Hypertension2,
published in April 2009, would result in an increase in referrals into secondary
care and additional pressure on the limited capacity within MYHT. Therefore,
in addition to ophthalmology being a pressured specialty, there are further
factors that could place the service under increased pressure.
Wakefield representatives took part in a ‘Route to a Solution’ exercise in early
2009 with Kirklees Primary Care Trust (PCT) and MYHT which explored
possible approaches to reduce the pressure on capacity at MYHT. Although
elements of work have been undertaken within aspects ophthalmology, there
has been a lack of understanding of the local need and complete
ophthalmology system in Wakefield District across all providers, both primary
and secondary care.
The purpose of this report is to:
 Provide an understanding of local need and the complete
ophthalmology system in Wakefield District.
 Enable commissioners to have discussions with stakeholders regarding
future ophthalmology services and to make informed decisions about
service design and commissioning intentions.
 Support achievement of NHS Wakefield District’s strategic objectives
on planned care pathways and delivering 18-weeks targets.
 Support an improvement in patient experience.
Information in this report has been drawn from a range of sources including
national policy and guidance, published data and documents, information and
data held within NHS WD and the knowledge and experience of colleagues
within NHS WD. Where possible, national comparator and benchmarking data
has been used.
Significant work is being undertaken separately to specify the Diabetic
Retinopathy Screening Service (DRSS) therefore, the analysis in this report
does not include DRSS.
A new hospitals development project will lead to the opening of new hospitals
in Pontefract and Wakefield in 2010 and 2011. Therefore, it is important that
any decisions on future eye care services take account of the new hospital
plans and associated capacity.
It is accepted that there are a range of stakeholders who will be able to
provide additional context and data to this report. However, it is aimed to be a
tool to enable further discussion. Suggested recommendations, based on the
information analysis, are made throughout the report to stimulate further
discussion.
4
3. HEALTH NEEDS
A Rapid Health Needs Assessment3 has been undertaken in relation to
ophthalmology in Wakefield District. This report should be read concurrently
with the needs assessment. This report does not seek to replicate the level of
detail in the document but summarises here some of the key findings.
The Wakefield District has a resident population of approximately 322,415
people. Projection figures suggest that the total population is expected to
grow to around 337,500 by 2017. The population is also forecast to grow in
line with England, rising 2.17% over the next five years 4. There are marked
expected increases in the over 65 and over 80 populations4 which will have
significant implications for ophthalmology services which are used more by
people in the older age groups.
The National Eye Health Epidemiological Model (NEHEM)5 and 2001 Census
data has been used to derive approximated prevalence of ophthalmic
conditions. By applying Office of National Statistics population projections to
this model it is possible estimate the predicted increase in conditions due to
demographic growth.
1.42%
2.01%
0.87%
6.70%
1.84%
3.96%
3.38%
0.58%
10.83%
1.35%
1.90%
0.82%
6.47%
1.74%
3.78%
3.24%
0.54%
Low Vision
Cataract Low
Geographic
Atrophy Cases
Source: NEHEM (2009), Public Health Intelligence Team
Severely
Impaired Sight
11.04%
0.80%
Impaired Vision
Low Estimated
Glaucoma Cases
0.84%
1.61%
Cataract High
High Estimated
Glaucoma Cases
1.69%
2.28%
Drusen Cases
2.39%
Wakefield District
Area (2001)
NV-AMD Cases
Y&HSHA PCT Average
AMD Cases
Mean Estimated
Glaucoma Cases
Table 1: Estimated Prevalence Rates for Key Ophthalmic Conditions
(2009)5
The needs assessment outlines projected need for ophthalmic services, both
in terms of numbers and percentage, in 2008, 2010, 2015, 2020 and 2025.
This information is broken down by the conditions Age-related Macular
Degeneration (AMD), Glaucoma, Cataracts and Low Vision with associated
impacts on the projected need and limitations of the data. A summary of the
projected need is presented below.
10.83%
10.94%
11.06%
11.83%
6.47%
6.50%
6.73%
7.80%
1.74%
1.77%
1.86%
2.28%
3.78%
3.91%
3.96%
4.47%
3.24%
3.33%
3.38%
3.79%
Source: NEHEM (2009), Public Health Intelligence Team (2009)5
5
Severely
Impaired Sight
Low Vision
0.82%
0.88%
0.93%
1.05%
Impaired Vision
1.90%
2.02%
2.15%
2.41%
Cataract Low
1.35%
1.43%
1.52%
1.69%
Cataract High
Low Estimated
Glaucoma Cases
0.80%
0.82%
0.82%
0.92%
Drusen Cases
Geographic
Atrophy Cases
1.61%
1.66%
1.68%
1.90%
High Estimated
Glaucoma Cases
2.28%
2.35%
2.38%
2.68%
Mean Estimated
Glaucoma Cases
Wakefield 2001
Wakefield 2008
Wakefield 2015
Wakefield 2025
NV-AMD Cases
Year
AMD Cases
Table 2: Projected Need for Key Ophthalmic Conditions, Wakefield
0.54%
0.58%
0.59%
0.68%
The projected need shows that the prevalence across all conditions is
predicted to rise. Therefore it is expected that demand for associated
ophthalmic services will also increase.
The needs assessment highlights that smoking, nutritional malnourishment
and hypertension may also impact on the level of need for ophthalmic
services. Furthermore a rise in obesity and associated diabetic retinopathy
would also affect the prevalence of visual ill-health.
The diabetic population of Wakefield is currently just over 15,000 representing
4.2% of the general practice registered population with an expected growth
rate of approximately 7.0% per annum6.
The needs assessment draws the following conclusions:
 Wakefield’s ageing population is likely to place additional strain on
Ophthalmology services over the next 25 years. Projections of future
need are currently crude and do not take account of other extraneous
and contributing factors. True need is likely to be in excess of the
projections in this document.
 In comparison to other areas, Wakefield District is not estimated (by the
NEHEM modeller) to have a higher level of need than that of other SHA
organisations. While prevalence estimates are relatively close between
neighbouring areas, Wakefield is consistently regarded as having a
lower level of need on each of the NEHEM outputs. While some of this
difference can be perhaps attributed to having a comparatively smaller
Black and Minority Ethnic (BME) population, the reliability of the
modeller will always be subject to questioning.
 Although the estimates of population need defined by the NEHEM
modeller may be lower that that of other areas in the Yorkshire &
Humber region, the true extent of ophthalmological needs may be more
than what is covered by the modeller. The four major eye conditions
may contribute the greatest use of resources, but other conditions
should be examined for their impact on service usage.
 Unmet need in visual problems (based on the definition found in the
lifestyle survey) increases with age, although the percentages in men
of all ages (except post-75) are higher. While there is not sufficient
evidence to suggest why this may be the case, there is evidence at a
national level that men are often reluctant to enter into treatment –
particularly where preventative treatment is concerned. That need is
higher in Wakefield North, Wakefield East and Knottingley.
6
4. CURRENT POSITION
4.1. Contracts and Providers Cost and Activity Profile
Looking at the contracts that NHS WD holds helps us to understand the
providers that we have and the associated cost of services for eye care
services. Activity and cost data has been summarised for primary and
secondary care services with actual figures for 2008/09 and planned or
estimated figures for 2009/10.
At present, PCTs do not hold the budget for primary optical services, such as
eye sight tests. These services are funded from a national budget which is
administered by West Yorkshire Central Services Agency (WYCSA). NHS WD
holds contracts with a number of optometrist practices and these practices are
authorised to provide NHS services in line with demand and so they do not
have set contracted levels of activity for the year.
Table 3: Summary of Total Activity and Cost
2008/09 (Actual)
2009/10 (Planned)
Activity
Cost (£)
Activity
Cost (£)
Secondary Care
45,890
6,246,574
34,870
5,001,432
Primary Care
120,634
3,212,562
3,692,434
Other Costs*
1,555
613,516
1,157
538,471
Grand TOTAL
10,072,652
9,232,337
* Other Costs include ARMD injections and fee paid to optometrists for cataract referrals
Note: This report does not include activity and costs for DRSS
Source: Summary Table - see tables below for individual sources
In 2008/09 eye care services in Wakefield District cost £10.07 million.
Contracts and estimated levels of activity for 2009/10 have a planned cost of
£9.23 million. However, it should be noted that actual activity data for 2009/10
shows that secondary care and Age-related Macular Degeneration (ARMD)
activity is exceeding planned activity. Therefore, actual costs in 2009/10 are
forecast to be higher.
Summaries of activity and costs for primary care, secondary care and
additional spend on ARMD and cataracts referrals are provided in the tables
that follow.
Secondary Care
The national mandatory Payment by Results (PbR) tariffs for 2009/107
determine the price that secondary care providers will be paid for outpatient
and admitted patient activity. The tariffs for ophthalmology services are listed
in appendices 1.1 - 1.2.
In 2008/09 the total cost of ophthalmology services in secondary care was
£6.25 million. Of this, £3.59 million (58%) was for admitted patient care with
the biggest proportion £3.39 million (54%) being on day case activity.
Outpatient care accounted for £2.65 million (42%) and this was split roughly
equally between the costs of first and follow-up attendances.
7
MYHT is NHS WD’s main provider of secondary care ophthalmology services.
In 2008/09, £5.00 million (80%) of the total cost of secondary care services
was with MYHT. The next two biggest providers in 2008/09 were LTHT
(£580k) and Birkdale Clinic (£426k).
Detailed information on contracts, providers, activity, costs, including
breakdowns by points of delivery can be found in appendices 1.3 – 1.10.
8
Table 4: Summary of Secondary Care Activity and Cost
Admitted Patient Care
Mid Yorkshire Trust
Activity
Cost
Actual
Actual (£)
4,009
2,778,918
Outpatient Care
33,505
2,219,052
4,981
295,889
2,397
137,184
40,883
2,652,125
Grand Total
37,514
4,997,970
5,520
822,347
2,856
426,257
45,890
6,246,574
Activity
Planned
3,850
Cost
Planned
1,703,110
Activity
Planned*
436*
Cost
Planned*
442,691*
Activity
Planned
430
Cost
Planned
273,605
Activity
Planned
Cost
Planned
4,716
2,419,406
23,235
2,139,032
4,359*
260,684*
2,560
182,310
30,154
2,582,026
2008/09 Actual
2009/10 Planned
Admitted Patient Care
Outpatient Care
Other NHS Trusts
Activity
Cost
Actual
Actual (£)
539
526,458
Birkdale Clinic
Activity
Cost
Actual
Actual (£)
459
289,074
TOTAL
Activity
Cost
Actual
Actual (£)
5,007
3,594,449
27,085
3,842,144
4,795*
703,375*
2,990
455,915
Grand Total
34,870
5,001,432
* 2009/10 planned contract activity for Leeds Teaching Hospitals Trust is not available by specialty therefore ‘actual’ activity and costs figures for 2008/09
have been added to the planned contract activity of the other NHS Trusts
Source: SUS, Provider Activity Returns and 2009/10 Contracts
Other NHS providers of ophthalmology services for NHS WD are:
 Bradford Hospitals NHS Trust
 York Health Services NHS Trust
 Sheffield Teaching Hospitals NHS Trust
 Doncaster & Bassetlaw Hospitals NHS Trust
 Leeds Teaching Hospitals NHS Trust (LTHT)
 Calderdale and Huddersfield NHS Trust
 Sheffield Children's NHS Trust
 Hull and East Yorkshire NHS Trust
9
MYHT Contract
In 2008/09 the total activity at MYHT was 4,364 under the planned level but
there was still an overspend of £323,601 due to overperformance in admitted
activity and the higher than planned cost of out-patient procedures.
During 2009/10 contract negotiations MYHT disclosed maximum capacity of
11,109 first out-patient attendances. NHS WD, as lead commissioner for the
trust, mapped the impact of this restriction on follow-up and day case capacity
and attributed the shortfall proportionately across all commissioners. For NHS
WD the variance between PCT expected demand and MYHT expected
capacity for ophthalmology, is estimated to be 3,984 first out-patient
appointments (77 per week), 9,164 out-patient follow up appointments and
1,300 day case episodes. This is a shortfall of 36% for out-patient
appointments and 34% for day cases. A total financial value of £1.73 million
has been removed from the NHS WD contract with MYHT.
Although this shortfall in activity was removed from the contract for 2009/10,
forecasts based on the first 2 months of activity data for 2009/10 show that
activity levels have not reduced. If the trend were to continue for the full year,
2009/10 volumes of activity would be equivalent to the expected level of
demand rather than planned volumes in contracts, based on capacity. This
reflects that sufficient alternative arrangements and providers have not been
put in place to meet the gap in capacity at MYHT.
Birkdale Clinic Contract
Birkdale Clinic is an independent healthcare provider, which provides
predominantly ophthalmology services. As the tables above show, Birkdale
Clinic has been a significant provider of ophthalmology services for NHS WD
with a planned contract for 2009/10 worth £455,915. In 2008/09, 9.17% of the
total admitted patient care and 5.86% of the total outpatient care for NHS WD
was provided by Birkdale Clinic.
Due to problems identified in a Healthcare Commission Inspection Report, the
PCT suspended the contract with Birkdale Clinic on 7 December 2007. It was
reinstated on 23 April 2008 following a further Healthcare Commission
Inspection which demonstrated improvement. During the suspension period
the provider was only permitted to see follow-up patients.
In 2008/09 Birkdale Clinic underperformed against planned outpatient activity
by 906 appointments (27%). The 2008/09 planned outpatient activity was
overstated because ‘Did Not Attend’ (DNA) levels were included in the
assumptions. 2009/10 plans do not include DNA appointments and therefore
better reflect activity at outturn. Outpatient activity was also affected by 23
days of the suspension falling within this period and the delay in referrals to
Birkdale Clinic resuming after the suspension.
Conversely, there was an overperformance against planned admitted patient
activity by 98 (27%) which can be attributed to addressing a backlog of
surgical procedures which accumulated during the suspension period and
initiatives to reduce waiting times at MYHT which included transfer of patients
10
to Birkdale Clinic for surgery. However, as this was on the basis of direct
listing and so the related outpatient activity was still undertaken at MYHT.
There are some concerns around the financial viability and clinical leadership
and governance of the organisation.
The contract with Birkdale Clinic is due to end on 31 March 2010. Following a
review of the service, it has been decided not to renew the contract and so
NHS WD will be looking to test the market.
Primary Care
Total spend on optical primary care activity was £3.04 million in 2007/08 and
£3.21 million in 2008/09. Based on costs for the first 6 months of 2009/10, the
projected annual spend is £3.69 million. The biggest proportion of costs is on
sight tests and optical vouchers. Activity data shows that in both of these
areas activity per 100,000 population in NHS WD is higher than the regional
and national averages. In 2008/09 the number of sight tests was 25,234 (14%
higher than the national average). The number of optical voucher items
processed was 10,499 (30% higher than the national average). See
appendices 1.11 – 1.12 for more detail on primary care activity and costs.
At present optical activity in primary care is funded through a national budget
and administered by WYCSA. This means that increases in activity are funded
centrally (projected cost increase of £480,000 for 2009/10). However, in the
future the budget may be transferred to PCTs to manage. This would mean
that increases in demand and activity (above planned funding) would be
a cost pressure for the PCT. Also, if the funding is transferred from the
centre to PCTs it may not come with current funding levels, may not be ring
fenced and projected growth would need to be funded by the PCT.
Table 5: Summary of Primary Care Activity and Cost
Activity
Cost (£)
2007/08 Actual
116,259
3,044,564
2008/09 Actual
120,634
3,212,562
April – September 2009 (6 months)
1,846,217
2009/10 Estimated*
3,692,434
* Annual optical primary care costs for 2009/10 have been estimated by assuming equal costs
in the second 6 months of the year as for the first 6 months of the year
Source: The NHS Information Centre for health and social care8 and NHS WD Finance data
Minor surgery for ophthalmology is not covered in any current Local Enhanced
Service (LES) and so such activity by GP practices would not be claimable.
Ophthalmology is not reflected in the Quality Outcomes Framework (QOF).
Additional Service Costs
As well as the activity and associated costs in primary and secondary care,
there are additional service costs associated with ARMD treatment and
cataract referrals which incur a referral fee for optometrists.
11
Table 6: Other Activity and Costs – ARMD and Cataracts
ARMD
Cataracts Referrals
Total
Activity
Cost (£)
Activity
Cost (£)*
Activity
Cost (£)
2008/09 Actual
809
583,676
746
29,840
1,555
613,516
2009/10 Planned
425**
509,191**
732***
29,280
1,157
538,471
* NHS WD pays optometrists a £40 fee for each cataracts referral. Therefore, the cost has
been based on £40 for each unit of activity (referral).
** ARMD 2009/10 planned activity and cost has been estimated using the plans for MYHT
and forecast for YEH based on actual activity and cost for 5 months 2009/10. Data for
2009/10 shows that MYHT are overperforming against plan and forecast activity is 664 with
cost at £971,615 (significantly higher than planned).
*** Cataracts 2009/10 planned activity and cost has been estimated based on actual activity
for 5 months 2009/10.
Source: Record of Optometrist Referrals in to PCT and SLAM
Administering injections for treatment of ARMD is a specialist procedure for
which providers require a licence. MYHT received special dispensation to
administer injections from July 2008. Prior to this NHS WD patients were
treated at Yorkshire Eye Hospital (YEH) but then transferred to MYHT, unless
they chose to keep their treatment at YEH. Forecast total activity at MYHT for
2009/10 is 664 procedures at £971,615. Therefore this is a very costly
service. See appendix 1.13 for more detail.
12
4.2. Referrals
The data (see appendix 2.1) shows that the total number of referrals for first
attendances (from all referral sources) has increased 23.7% in 2007/08 and
10.9% in 2008/09 compared to the previous years.
The number of follow-up attendances has remained fairly static, indicating a
reduction in the first to follow-up ratio. The reason for this is not clear. It could
be due to a higher proportion of first attendances that are immediately
discharged, requiring no further appointments (indicating that some referrals
may be inappropriate) or due to a reduction in the total number of follow-ups
for each patient. This area would merit further investigation.
In the three years, the proportion of referrals originating from GPs has
remained fairly static at slightly over half of the total number of referrals (53.35
- 56.92%). The proportion of self-referrals has also remained reasonably
constant (2.79 – 3.27%). However, referrals from consultants (not A&E) e.g.
consultant to consultant referrals, have increased from 10.66% in 2006/07, to
15.59% in 2007/08 and 18.69% in 2009/10 but it is not clear why.
It should be noted that the accuracy of this data is dependant on the quality of
coding. It is notable that in 2006/07 there were 938 (10.99%) first attendances
without a referral source entered. Although this has reduced to less than 1%
in subsequent years, “other: not Consultant responsible for out-patient”
referrals have risen to 8.26 - 9.87%. Therefore, there are still a high proportion
of referrals without a clear source identified.
Furthermore, it is not possible from this data to identify referrals initiated by an
optometrist. This is likely to be because optometrist referrals are routed
through GPs or the PCT. There was a proposal previously to facilitate direct
referrals from optometrists to secondary care but this was not established.
This means that we do not have a clear picture of the true source of
referrals. If work was to be undertaken in future to refine the referrals that
GPs and Optometrists make into secondary care, further detail would be
needed.
Recommendation: Investigate reason for reduction in first to follow-up
ratio
Recommendation: Amend coding practice to reflect referrals initiated by
optometrists accurately
Recommendation: Facilitate direct referrals from optometrists to
secondary care
NHS Comparator data (see appendices 2.2 - 2.3) suggests that NHS WD’s
standardised rate of first attendances per 1000 population (32.2) is slightly
lower than the SHA average (33.0) but higher than the national average
(29.9). Whereas, the standardised rate of first attendances per 1000
population, referred from GPs (18.2) is higher than both the SHA (16.5) and
the national averages (15.8). As these rates are standardised they have
13
already been adjusted based on the age and sex profile of the local
population.
As noted above, referrals initiated by optometrists are not recorded and
reflected in the data. It is probable that these referrals are being recorded as
GP referrals and therefore artificially inflating the number of GP referrals so
that the rates appear high in comparison to the SHA and national averages.
It must be noted that NHS Comparator data is taken from SUS and, as
Birkdale Clinic does not submit SUS returns, a significant proportion of first
outpatient activity in 2008/09 (506 attendances, 4.29% of total first
attendances) is not captured in this data. Therefore, NHS Comparators
underestimates the rates for NHS WD. As SUS is the main data source for
secondary care activity this anomaly will affect other data analysis. It is
particularly significant for ophthalmology because Birkdale is a significant
provider of ophthalmology services for NHS WD.
Recommendation: Require Birkdale Clinic to submit data returns via
SUS or explore ways to ensure that all provider activity is included in
data analysis.
Diagram 1 shows that there is wide variation in the rate of ophthalmology
referrals from GP practices (8.8- 24.4). As the data uses standardised rates,
this can not be accounted for by differences in the sex or ages profiles of the
registered patients. However, in part, it could be due other demographic
differences or health needs.
White Rose and Rycroft Surgeries offer internal ophthalmology clinics which
explains their lower referral rates. The other ‘low’ referring practices are all
located on the East of the district which has historically referred more patients
to Birkdale Clinic. As Birkdale activity is not reflected in this data, the rates for
these practices may appear artificially low. Nonetheless, there may still be
variations in referring practice between GPs which will contribute to some of
the difference.
14
Diagram 1: Outpatient First Attendances per 1000 Population (New), Referred
by GPs 2008/09
Standardised
Rate
PCT
18.2
SHA
16.5
National
15.8
Lowest 7 referrers:
White Rose, 8.8
Ash Grove, 9.7
The Grange, 10.9
Friarwood, 12.0
Rycroft, 13.1
Ferrybridge, 14.8
Queen St, 15.0
Total Count
6,408
89,731
858,434
Expected
Count
1,670
25,847
258,031
Count
Difference
4,738
63,884
600,403
% Difference
283.7
247.2
232.7
Highest 7 referrers:
Eastmoor, 24.4
Welbeck St, 24.3
New Southgate, 22.6
College Lane, 22.1
Maybush, 22.0
Tieve Tara, 21.8
Newland Lane, 21.7
15
4.3. Pathways
Patient pathways reflect the various entry points and the possible journeys
that a patient with a particular condition may take through the health system.
Improved pathways can reduce the resources (staff, time, buildings and
equipment) required to deliver health services, improve the patient
experience, reduce the overall cost of services and improve outcomes.
Therefore, understanding pathways is a key element of service improvement.
There is a lack of clarity about current local pathways for eye conditions.
Recommendation: As service specifications are developed for eye care
services, commissioned pathways should be discussed and embedded.
Examples of national recommended pathways can be found in appendices
3.1 – 3.2.
16
4.4. Casemix
Patient pathways and service planning for ophthalmology are normally aligned
to particular conditions such as cataracts and glaucoma. Therefore, it is useful
to understand activity, broken down by condition (see appendices 4.1 - 4.2).
However, this information is not readily available. Secondary care admitted
patient activity is recorded by Health Resource Group (HRG) but these are not
directly comparable with conditions. Future Sight Loss UK (1)9 outlines an
approach which maps HRG descriptions to eye conditions. This approach has
been applied to Wakefield District secondary care activity data. This only
provides an estimation of activity by condition as some HRG codes will not
map entirely to one condition but it is a useful tool nonetheless.
Unfortunately, due to the way that outpatient activity is currently coded (all
outpatient attendances are simply coded by specialty), it is difficult to
breakdown by condition. However, Future sight loss UK (1)9 details outpatient
costs for England, sourced from reference costs data, split by eye conditions
using the HRG descriptions mapping system. Assuming that the profile of
outpatient activity by condition in Wakefield District is broadly comparable to
the national picture this gives an indication of the relative costs of outpatient
activity by condition.
Diagram 2: Admitted Patient Activity, by Condition, April 2007 – August 2009
6,000
5,000
Volume of Activity (spells)
Cataract
Diabetic Retinopathy
4,000
Other
3,000
Age-Related Macular
Degeneration
Glaucoma
2,000
Refractive Error
1,000
0
2007/08
2008/09
2009/10
Grand Total
*2009/10 data includes 5 months, April 2009 – August 2009
Source: SUS
The data shows cataracts makes up over 50% of admitted patient activity,
with diabetic retinopathy being the next biggest at 21%. As expected, ARMD
and glaucoma only represent a relatively small proportion of admitted patient
activity (3% each) because most activity for these conditions is carried out
within outpatient settings.
17
Table 7: Outpatient Costs for England 2008, by Condition
Outpatients
Observation
Wards
Total
Outpatient NHS
Total
Outpatient –
non NHS
£ million
£ million
£ million
£ million
Total
Outpatient –
NHS and
non NHS
£ million
ARMD
0.00
0.65
0.65
0.01
0.65 (3%)
Cataracts
1.74
0.00
1.74
1.72
3.47 (16%)
Diabetic
Retinopathy
10.31
0.01
10.32
0.00
10.32 (48%)
Glaucoma
0.83
0.00
0.83
0.00
0.83 (4%)
Refractive
Error
2.26
0.05
2.32
0.00
2.32 (11%)
Other
3.77
0.00
3.77
0.00
3.77 (18%)
TOTAL
18.91
0.71
19.63
1.73
21.36
Source: NHS Reference Costs Collection 2006-07, Future sight loss UK (1)9
The data shows that nationally 48% of outpatient costs is attributable to
diabetic retinopathy. Wakefield District’s DRSS is provided by Wakefield
District Community Healthcare Services (WDCHS) and, other than
ophthalmologist input from MYHT, is a stand alone service. Therefore, for the
purposes of this report, it is useful to analyse the proportions excluding DRSS.
Of the remaining costs, 31% are on cataracts, 8% on glaucoma, 6% on ARMD
with the other 55% split between refractive error and other eye diseases.
Therefore, cataracts is the condition which takes up the biggest proportion of
both admitted patient and outpatient care and is potentially an area where the
biggest improvements could be made. Although, according to this data,
glaucoma does not take up the biggest proportion of admitted patient and
outpatient care, ongoing management of glaucoma patients does absorb
secondary care capacity which could potentially be released.
Recommendation: Outpatient activity broken down by condition is an
area that would require further work. Possibilities include further
analysis of outpatient data, an audit of referrals and outpatient activity
or changes to coding practice.
Recommendation: Cataracts is the condition which takes up the biggest
proportion of both admitted patient and outpatient care and is
potentially an area where the biggest improvements could be made.
Recommendation: Improvements in the glaucoma pathway could
release secondary care capacity.
18
4.5. Quality and Patient Experience
Patient experience is one of the key dimensions of quality. In order to gain an
understanding of the level of patient satisfaction with ophthalmology services
and ultimately the quality of services, this section examines:
 Outpatient cancellations and DNAs
 Waiting Times
 Choose and Book Slot Availability
 Public and patient feedback, including engagement event, NHS
Choices, Complaints and PALS
 Serious Untoward Incidents
 Quality reports
4.5.1. Out-Patient Cancellations and DNAs
The Dr Foster comparator data (see appendix 5.3) shows that there are very
few outpatient cancellations for NHS WD and MYHT. Assuming that the data
is accurate, this is a very strong area of performance for both organisations.
Conversely, the outpatient DNA rates are higher for NHS WD and MYHT than
the national and SHA averages. For first appointments NHS WD is 8% and
MYHT is 9% compared to an average of 6% nationally and regionally. For
follow-up appointments NHS WD is 10% and MYHT is 12% compared to an
average of 8% nationally and regionally. Although DNA rates can be
influenced by the demographics of the local population, there are also actions
and changes that providers can make to reduce DNA rates and hence release
some of their capacity. This may be an area in which to focus improvement in
NHS WD.
Recommendation: Consider ways to reduce outpatient DNAs across
NHS WD and especially at MYHT
4.5.2. Waiting Times
The Department of Health has set a maximum patient journey of 18 weeks
from referral to start of treatment. PCTs and providers are expected to meet
18 weeks for a minimum of 90 per cent of admitted patients and 95 per cent of
non-admitted patients from January 2009.
The data (see appendices 5.6 – 5.7) shows that in 2008/09 in Wakefield
District 85% of admitted patients and 92% of non-admitted patients started
treatment within 18 weeks. As such a high proportion of NHS WD
ophthalmology activity (82%) is undertaken by MYHT, the performance of this
trust is fundamental to the delivery of 18 weeks for the population of Wakefield
District.
In 2008/09 MYHT (see appendices 5.8 – 5.9) achieved 18 weeks for 83% of
admitted patients and 92% of non-admitted patients. In the 14 months to May
2009, MYHT only met the admitted patient target in 4 months and the nonadmitted patient target in 3 months. The trust performance in March, April and
May 2009 appears to have improved which could indicate progress towards
the 18 weeks standard during 2009.
19
Even though MYHT may have improved its 18 weeks performance, the
cumulative profile in Diagram 3 shows that a high proportion of MYHT patients
are being seen just before the 18 week point e.g. in week 17 of their journey.
MYHT is achieving its 18 week standard, in part, by transferring patients to
alternative providers part way through their journey. This approach is not
conducive with delivering an improved patient experience or in achieving
sustainability. See appendix 5.10 for a non-cumulative chart.
Diagram 3: Admitted Patient Waiting Times Cumulative Profile
Aggregate data for July - Sept (provisional)
Ophthalmology
cumulative proportion of organisation's patients (for this PCT)
treated in each week
100%
90%
80%
70%
60%
50%
WAKEFIELD DISTRICT PCT
40%
MID YORKSHIRE HOSPITALS NHS TRUST
30%
IS PROVIDERS
20%
ALL OTHER PROVIDERS
10%
'IDEAL' PROFILE
18 weeks
15 weeks
8 weeks
52 plus
>50-51
>48-49
>46-47
>44-45
>42-43
>40-41
>38-39
>36-37
>34-35
>32-33
>30-31
>28-29
>26-27
>24-25
>22-23
>20-21
>18-19
>16-17
>14-15
>12-13
>8-9
>10-11
>6-7
>4-5
>2-3
>0-1
0%
weeks waited
Source: NHS Yorkshire and the Humber
Also there was a noticeable dip in performance, particularly for admitted
patients, between September 2008 and January 2009. This may have been
due to winter pressures and if this is replicated in 2009/10 we would expect to
see deterioration in performance during the winter months. Therefore, it would
be very difficult for the trust to achieve the 18 weeks standard in
ophthalmology without changes in working practices and patient
management, investment in additional capacity, or a reduction in demand.
Recommendation: Continued monitoring of provider RTT times and
work with providers to improve performance and deliver a greater
proportion of patient treatments earlier in their pathway
4.5.3. Choose and Book Slot Availability
The number of unavailable slots on Choose and Book reflects patients being
unable to book an appointment with the provider of their choice and therefore
a high number of unavailable slots is detrimental to the patient experience.
The number of unavailable slots on choose and book is monitored by
20
specialty on a weekly basis. Performance against this measure has been
included within the 2009/10 contract.
Diagram 4: MYHT Ophthalmology Choose and Book Slot Availability
90
Number of Unavailable Slots
80
70
60
50
40
30
20
10
09/08/2009
02/08/2009
26/07/2009
19/07/2009
12/07/2009
05/07/2009
28/06/2009
21/06/2009
14/06/2009
07/06/2009
31/05/2009
24/05/2009
17/05/2009
10/05/2009
03/05/2009
26/04/2009
19/04/2009
12/04/2009
05/04/2009
0
Date
Data for MYHT, in diagram 4 shows that ophthalmology has been in the 5
specialties with the highest number of unavailable slots in every week
between 5 April 2009 and 9 August 2009. The chart above shows that there
has been variation in the number of issues week to week, however it is a
consistently poor performing specialty. Furthermore, the number of
unavailable slots has been higher since mid-June 2009 than prior to this.
Therefore, there is no sign of improvement.
MYHT has temporarily removed ophthalmology from the direct booking facility
on choose and book so that appointments can only be booked in-directly
through their own booking team. This allows MYHT more control and the
ability to manage appointments but places an additional requirement on them
to administer all ophthalmology bookings. The inability to book directly is
detrimental to the patient experience.
4.5.4. Local Needs and Priorities
The Wakefield Speaks and A Question of Health public events have helped
NHS WD to understand the needs and priorities of local people. Although, the
reports of these events do not include specific information regarding eye care
services, the broad principles of want local people want from health services
are still relevant for this service area.
21
People told us that they want:
 To see the same professionals wherever possible;
 More time with staff so they can listen and respond to practical and
emotional needs;
 More flexible systems so that people can book appointments at times
and in places convenient to them;
 The PCT to provide more services in the community whenever
possible, although they accept that they may have to travel further for
very specialist services;
 To be able to get as many things done as possible on each visit to an
NHS service to reduce the number of trips they have to make;
 Staff within a service, and across different services, to work together
better.
Priorities that were particularly pertinent for planned care were:
 Make sure people can get as much done as possible in any single
appointment (including access to a range of diagnostic services);
 Make sure services are provided in community settings, as close to
home as possible;
 Have a wider range of staff trained to provide planned care services
closer to home.
NHS Choices website
The NHS Choices website enables patients and the public to give feedback
about NHS services. A search of the website in August 2009 showed that no
comments had been left in relation to ophthalmology services at MYHT.
Complaints and PALS enquiries
In 2008/09 NHS WD received one complaint about the service provided by an
optician and one complaint about the Diabetic Retinal Screening Service.
NHS WD does not have any record of other complaints relating to
ophthalmology services.
NHS WD complaints department does not hold records of complaints
regarding all provider organisations unless they are directed to NHS WD. For
detailed information about complaints across all ophthalmology services,
information would have to be obtained from providers. A request was sent to
MYHT asking for details of service user and carer opinion, complaints and
compliments but no information has been returned at the time of writing this
report.
Recommendation: Ensure that providers are contractually required to
provide regular reports to NHS WD on complaints, including trend and
theme analysis
The NHS WD Patient Advice and Liaison Service (PALS) did not receive any
queries related to ophthalmology services between 1 December 2008 to 23
July 2009. The PALS database does not record enquiries made before this
date.
22
Overall, there is very limited local information on what the Wakefield
District population expect and want from eye care services.
Recommendation: Explore methods to engage with the public and
patients and find out their expectations and what they want from eye
care services
4.5.5. Serious Untoward Incidents (SUIs)
NHS WD Risk Management Department do not hold any record of SUIs
relating to ophthalmology in 2007/08, 2008/09 or 2009/10 (up to September
2009).
NHS WD does not hold records for SUIs within secondary care providers.
Recommendation: Ensure that providers are contractually required to
report SUIs to NHS WD
4.5.6. Service Quality
The Care Quality Commission (CQC) regulates health and social care in
England. Its work includes:
 Registration of providers to ensure they are meeting essential common
quality standards
 Monitoring and inspection
 Using enforcement powers if standards are not being met
 Undertaking regular reviews of the planning and provision of locals
services, particular care services or pathways
 Reporting the outcomes of CQC work
Prior to 1 April 2009 the Healthcare Commission (HCC) undertook this work in
relation to healthcare.
Searches of standard quality information did not show any specific references
to ophthalmology services for any of our main providers (MYHT, LTHT or
Birkdale Clinic). However, Birkdale Clinic is predominantly an ophthalmology
provider and NHS WD only contracts with this provider for ophthalmology
services. Therefore, whilst ophthalmology services were not specifically
referenced in the inspection report for this provider, general findings for this
provider will be particularly pertinent to ophthalmology services.
As highlighted is section X, due to problems identified in a Healthcare
Commission Inspection Report, the PCT suspended the contract with Birkdale
Clinic for nearly 5 months in 2007/08.
Summary reports, which offer a general overview of the standard of quality,
can be found at www.cqc.org.uk.
23
4.6. Patient Choice
Choice is a key component of the Government’s drive for a patient-centred
NHS as it empowers people to get the health services they want and need.
The NHS Constitution10 sets out choice as a right and PCTs are now legally
required to ensure that patients get Free Choice on referral to a consultant-led
service.
There are a range of providers of secondary care ophthalmology services
available on the Choose and Book menu. However, outpatient activity in
2008/09 shows that 88% of NHS WD first attendances and 80% of follow-ups
were provided at MYHT. This indicates that less than 20% of our patients are
choosing alternative providers. The demographics and attitudes of the local
population impact on the proportion of patients that decide to choose an
alternative provider. We understand that many of NHS WD’s population want
to access services locally to where they live.
There may be benefit in developing the range of providers available, in
particular, alternatives that can offer local services.
Optometrists make a number of referrals for cataracts. However, they do not
have Choose and Book and so do not offer patients choice of provider. In
order to ensure that patients are offered choice and to increase the number of
patients choosing alternatives to MYHT and relieving pressure on their
service, NHS WD set up a system through which optometrists refer via NHS
WD where choice is offered. A flat fee of £40 is paid to optometrists for each
cataracts referral. It is understood that a further £15 payment is made by
MYHT to optometrists for any aftercare/follow-up that they provide for patients
attending MYHT.
This system was part of a revised cataract pathway for Wakefield District,
including optometrists providing pre-operative and post-operative care.
However it is not clear how much of the pre-operative and care optometrists
are providing, for example, whether they are undertaking diagnosis;
discussion of impact on lifestyle; discussion of risks and benefits of surgery;
self-assessment questionnaire; suitability for surgery. It is also not clear what
proportion of post-operative follow-ups are being undertaken by optometrists
and at what point they are discharged from secondary care. This area would
merit further investigation.
There is potential for optometrists to play a greater role in the patient
‘work-up’ prior to referral.
Recommendation: Undertake work to understand how cataract pathway
is operating and to what extent optometrists are undertaking pre and
post-operative care
Recommendation: Refresh cataract pathway to enable optometrists to
refer directly to secondary care, undertake pre-operative care, list
directly with secondary care for surgery, undertake post-operative care
24
Recommendation: Investigate possibility of installing Choose and Book
software in optometrist practices to enable them to offer patients choice
and refer electronically.
The National Eye Care Services Steering Group First Report11 and
Commissioning Toolkit for Community Based Eye Care Services12
recommend a pathway where community optometrists play a much more
significant role in the diagnosis and preparation for surgery of the patient, and
in the postoperative period.
The data (see appendices 6.2 – 6.3) reflected in diagram 5 shows that the
proportion of patients choosing an alternative provider to MYHT for cataracts
in 2007/08 (6.64%) and 2008/09 (3.08%) was very low. However, there has
been a sharp increase and in each month in 2009/10 to July 2009 the number
of people choosing an alternative provider (other than MYHT) has increased.
This reached a high of 42% in July 2009. This suggests that patients are
better informed that they are entitled to choice, have more information about
alternative providers and are more willing to choose alternatives.
Diagram 5: Cataracts Referrals, Choice of Provider
120.00%
% Referrals to Provider
100.00%
80.00%
MYHT
60.00%
Other Providers
40.00%
20.00%
20
09
Ju
ly
20
09
Ju
ne
20
09
ay
M
20
07
/2
00
8
20
08
/2
00
9
20
09
/2
01
0*
Ap
ril
20
09
0.00%
Source: Record of Optometrist Referrals into PCT
Recommendation: Explore ways to further raise awareness of Free
Choice among patients, provide information to support patient choice
and encourage GPs and other primary care clinicians to inform and
support patients at the point of referral
Recommendation: Continue to develop the provider market, in particular
providers that can offer additional capacity in local, accessible settings
25
The table in appendix 6.4 lists potential alternative providers of ophthalmology
services identified through internet searches. There may be other providers,
particularly national providers or Foundation Trusts, that would be interested
in providing ophthalmology services in Wakefield District. A soft market
analysis has not been undertaken but would be recommended if NHS
WD wished to explore the option of alternative providers further.
Recommendation: Carry out soft market analysis to understand the
potential provider market if NHS WD wished to develop a wider range of
alternative providers
26
4.7. Incentives to Drive Up Performance
NHS WD utilised a local incentive scheme (LIS) to encourage GP practices to
undertake a review of ophthalmology referrals and follow-up appointments in
secondary care. The purpose of this was to gain an understanding of practice
in secondary care and where there are opportunities for improvement. 36
practices returned comments following a review of ophthalmology follow-ups
in Q1 of 2008/09. The key comments are summarised in the table below.
Table 8: Ophthalmology Follow-Ups – LIS 2008/09 Q1 Feedback from GP
Practices
Comment
Number of practices
raising
Lack of letters or information from hospitals (includes discrepancies
8
between number of follow-ups and letters sent to practice)
Review/monitoring of patient could occur within the community e.g.
12
optician, optometrist, GPwSI (in particular, for glaucoma patients)
Patients could be repatriated to the community
4
Follow-up could be avoided by advice (GP/GPwSI)
2
Direct referrals possible for some patients
3
Optical intermediate/triage service would be beneficial e.g. higher
6
level specialty community optician, GPwSI
Patients attending for follow-up are receiving ongoing treatment
1
Most follow-ups appropriate
10
Source: Practice feedback, LIS Q1 2008/09 ophthalmology follow-ups
10 practices commented that most follow-ups were appropriate. However,
particular concerns were raised around the lack of information and letters
provided from hospital trusts to GPs. Furthermore, it was suggested
repeatedly that review and monitoring of patients could be undertaken by
appropriately skilled professionals in the community. It was also suggested
that a community service providing intermediate care or triage would be
beneficial.
Recommendation: Improve communication between primary and
secondary care
Recommendation: Consider possibilities of greater review/monitoring
and intermediate services within community setting
27
4.8. Workforce
Table 9: Ophthalmic Services Community Workforce
Mandatory Only Contractors
Additional Only Contractors
Mandatory and Additional Contractors
Total Number Contractors
Number of Performers (individuals)
Number of Performers Working*
Number
15
17
23
55
91
125
Notes:
*One performer may work in a number of different practices therefore appearing as a
performer in several different contracts
Mandatory Contracts: standard ophthalmic services at a fixed address
Additional Contracts: provides domiciliary services
Source: West Yorkshire Central Services Agency
National figures taken form General Ophthalmic Services: Workforce Statistics
for England and Wales13 show that NHS WD has 17.1 ophthalmic contractors
per 100,000 population compared to 19.0 in Yorkshire and Humber SHA and
18.7 nationally. Although described as ‘ophthalmic practitioners’ in the
statistics, these numbers are based on contractors. However, the local activity
will be delivered by the performers, rather than contractors alone, and
therefore this would be better comparison. This information was not available
on a national level. The primary care activity, outlined earlier in this report
shows higher levels per 100,000 population in NHS WD. Therefore, delivering
higher levels of activity with a lower number of contractors may demonstrate a
more efficient service or that contractors use a greater proportion of their
resource for NHS activity compared to other areas which may have a greater
proportion of private activity.
28
5. SERVICE PRESSURES
The data and analysis within the ‘current position’ section of this report
identifies a number of potential and actual service pressures. These are
summarised below.
 Projected increase in the population and, in particular in the number of
over 65s and over 80s. Projected increase in the prevalence of all
ophthalmic conditions. This could be inflated further if other factors
which can impact on eye health also increase, such as smoking,
diabetes and hypertension. Further details can be found in section 3.
 Gap between MYHT expected capacity and NHS WD expected
demand for ophthalmology services in 2009/10. Although the 2009/10
contract was reduced accordingly, activity so far has been
overperforming at levels of the expected demand rather than capacity.
Further details can be found in section 4.1.
 The contract with Birkdale Clinic is due to end on 31 March 2010. If it is
not renewed this would result in increased demand for services at our
other providers, predominantly MYHT, unless an alternative provider is
established. Further details can be found in section 4.1.
 Lack of facility for optometrists to refer directly to secondary care.
Further details can be found in section 4.2.
 Inefficient pathways which duplicate steps or rely on secondary care to
undertake the bulk of the pathway. Further details can be found in
section 4.6 and 4.7.
 Patient choice to receive treatment from alternative providers (other
than MYHT) has increased. However, Wakefield District population’s
appetite for alternative providers has traditionally been fairly low. The
older demographic of the patient group requiring ophthalmology
services means that a significant proportion will wish to choose MYHT.
Therefore, the uptake in alternatives may plateau or alternative options
and the offer of choice will need to be made more attractive to
encourage take up. Further details can be found in section 4.6.
 Waiting times. Waiting lists require administrative management. Also
operating with a high proportion of patients only being seen just before
the 18 week point leads to additional pressure in the system. Extra
resource is absorbed in avoiding breaches. Further details can be
found in section 4.5.2.
 It is possible that the responsibility and budget for primary care eye
care services will transfer from the national government to PCTs. This
would mean that NHS WD would have to manage any financial
pressure due to demand for primary care eye care services in excess
of plan. Further details can be found in section 4.1.
 Increasing number of referrals for first attendances and comparatively
high referral rates compared with the national average mean that there
is a high level of demand for secondary care services. Further details
can be found in section 4.2.
 High rates of DNAs (at MYHT) lead to inefficiency and wasted capacity
within the service. Further details can be found in section 4.5.1.
29

High numbers of unavailable slots on the choose and book system (at
MYHT) demonstrate inefficiency in the capacity planning and clinic
scheduling. The temporary change to make ophthalmology only indirectly bookable required MYHT to administer all bookings. Further
details can be found in section 4.5.3.
Some other key service pressures are summarised below.
5.1. Diabetic Retinopathy Screening Service (DRSS)
The diabetic population of Wakefield is currently just over 15,000 representing
4.2% of the general practice registered population with an expected growth
rate of approximately 7.0% per annum6.
The DRSS is provided by WDCHCS. The DRSS requires input from
ophthalmologists and therefore support is provided by the ophthalmology
service at MYHT. The role of the ophthalmology service at MYHT is twofold:
 To ensure patients attending DRSS have access to prompt referral and
high quality referral, assessment and treatment if their condition
necessitates; and
 To provide education, clinical supervision and general support to
DRSS.
Historically the role of MYHT has not been clearly defined, quantified, nor had
appropriate clinical time and correlating funding attributed to it. There has
been variation in the ophthalmologist time allocated to DRSS, linked, in part,
to the turnover of consultant ophthalmologists and capacity at MYHT.
Insufficient consultant ophthalmologist capacity to DRSS had led to the build
up of a backlog of work, in particular in the Ophthalmic Photographic Diabetic
Review (OPDR) group of patients. This has now been cleared by instigating a
waiting list initiative, whilst discussions about capacity for this type of work are
progressed.
Discussions between commissioners, DRSS and MYHT have estimated that
the ophthalmology service at MYHT would need to provide a total of 8
sessions per week in order to fulfil the requirements of supporting the DRSS.
This is broken down by:
 5 sessions for assessment and treatment
 2 sessions for OPDR grading and assessment
 1 session for support, supervision, data collection, reporting and
training to DRSS staff
1 session a week is currently commissioned from the DRSS for
ophthalmology input but due to this not being clearly specified a mix of
assessment, grading and supervision has historically taken place within this
funded session.
A draft service specification for the requirements of ophthalmology in order to
both support the DRSS and to provide assessment, grading and treatment as
per the national requirement is currently being drafted for negotiation with
30
MYHT. This would also support a tender process, if, in the future, a decision
were to be taken that MYHT was not able to provide this service and an
alternative provider was required.
5.2. New NICE guidance for Glaucoma
National Institute for Health and Clinical Excellence (NICE) guidance on
Glaucoma and Ocular Hypertension2 was published in April 2009. The
guidance recommended that the threshold for referring patients with
suspected glaucoma be lowered. The Association of Optometrists (AOP)
advised the profession that it must adhere to the guidance and ensure that
anyone meeting the criteria is referred in order to avoid legal challenge.
Although NICE later published a ‘clarification notice’ emphasising that the
patient’s diagnostic measurement should be consistently elevated, it is likely
that optometrists will follow the AOP advice.
Very few optometrists have the skills, qualifications or equipment to be able to
diagnose glaucoma in line with the guidance. Therefore, it is expected that the
guidance will result in a significant increase in suspected glaucoma referrals
to secondary care. Even though the guidance accepts that it will take 3-5
years to establish capacity to meet the requirements, initial indications are that
optometrists are already referring in line with the NICE guidance and the AOP
advice. MYHT has raised concerns that they have already experienced a
dramatic increase in the rate of referrals and that a high proportion of these
are not positive cases on diagnosis.
The estimated build up to achieving the capacity needed to meet additional
demand is 30% in year 1, increasing to 60% in year 2 and 100% in year 3.
The total national costs in year 1 are estimated to be £4 million, rising to £8
million in year 2 and £13 million in year 3. For Wakefield District, it is
estimated that £77,500 in costs will be incurred following the guidance,
generated by the increase in secondary care referrals. This was based on a
population of 315,00014.
It is possible that a glaucoma referral refinement scheme delivered by
community optometrists could relieve pressure on secondary care. Any such
scheme would require Goldmann Applanation Tonometry (GAT) and an
appropriately skilled and supervised workforce. Of the 38 optometric practices
visited up to the end of 2008, 15 had an applanation tonometer, 6 of which
had a GAT14.
31
6. OPTIONS APPRAISAL
After consecutive years of funding increases, it is suggested that the NHS will
be required to find savings of between £15 and £20 billion between 2011 and
201415. However, there will still be an expectation of the NHS to deliver
against High Quality Care for All and the Quality, Innovation, Productivity and
Prevention (QIPP) agenda and key standards such as 18 weeks. Therefore,
commissioning decisions need to take all of these factors into consideration.
National work and documentation outlines proposed pathways for eye care
services with optometrists and other community practitioners playing an
increased role in the provision of services. The National Eye Care Steering
Group First Report11, Commissioning Toolkit for Community Based Eye Care
Services12 and the LOC Support Unit proposals for Enhanced Optometric
Services16, including PEARS, Glaucoma, and Cataract schemes all advocate
similar approaches to the development of eye care services. This report will
not seek to repeat the detail provided in these documents. Instead it gives a
brief overview of the three main options for development: PEARS; glaucoma
referral and refinement; and pre and post-operative cataract services. Further
details can be found in the documents referenced. The National Eye Care
Steering Group First Report11 pathways for glaucoma and cataract are
provided in appendices 3.1 - 3.2.
All of the proposals seek to retain patients within the community care setting,
wherever possible. This is in line with the principles of Our Health, Our Care,
Our Say17, World Class Commissioning and High Quality Care for All18 as it is
about providing care closer to home, ensuring patients receive the right
treatment, from the right professional, at the right time and that services are
patient-centred.
The broad benefits of this kind of approach are outlined below.
To patients:
 Care closer to home or work
 Easier access
 Wider choice of venue and appointment times
To PCTs/Practice-Based Commissioners:
 Reduction in new referrals to secondary care
 Reduction in outpatient follow-ups
 Assistance towards achieving 18 week standard
 Greater patient choice
 Better use of resources
To other stakeholders (including secondary care):
 Improved quality of referrals
 Increased capacity
 Closer working between GPs, Pharmacists, and local Optometric Practices
32
To practitioners and practices:
 Common accreditation
 Ability to use their skills to their full extent
Additional benefits:
 Performance monitoring
 Improved data collection, including patient reported outcome measures
(PROMS)
 Smoking cessation and other public health messages could be included
Source: LOCSU Enhanced Optometric Services
Whilst there is strong evidence of the potential benefits of greater provision
within the community, this approach should not be seen as an instant cost
improvement measure. Community provision would help to reduce waiting
times in secondary care by reducing demand and releasing capacity.
However, unless equivalent spending is removed from secondary care,
effectively by capping activity, immediate savings would not be realised.
Schemes to increase community provision will also have initial set up costs.
Three key community schemes are considered here. These are:
 Primary Eyecare Acute Referral Scheme (PEARS)
 Glaucoma Referral Refinement and Ocular Hypertensive Monitoring
 Pre and Post Operative Cataract Service
There have been local discussions of the benefits of implementing PEARS.
This would require cooperation between the primary care and planned care
commissioning portfolios.
6.1. Primary Eyecare Acute Referral Scheme (PEARS)
 Acute eye care problem e.g. red eye
 Accredited optometrists provide service
 Examination appropriate to the reason for referral, diagnosis and decision
on management within service, discharge or onward referral
 In high street optical practices or GP practices
 GP or self-referral
 Fast access e.g. with 24 hours if urgent and within 2 weeks if routine
Benefits:
 Short waiting times (within 2 weeks)
 Majority of patients retained and safely managed within primary care
(75–80% indicated in findings from schemes elsewhere)19
 Reduces referrals into secondary care
 Refines referrals and ensures they are appropriate and timely
 Majority of referrals into secondary care deemed to be appropriate
 High patient satisfaction
(95% ‘very satisfied’ and 5% ‘fairly satisfied’ with WECI)19
 Better access, equity of access and shorter travelling times
33
Issues:
 Modest cost savings (SOAP) or low cost, considering clinical benefits and
patient accessibility (WECI)
 Although reduces referrals into secondary care, for those patients
ultimately referred into secondary care this adds an extra ‘step’ in their
journey, which also has a cost implication
Examples:
 Welsh Eye Care Initiative (WECI) encompasses a PEARS and Welsh Eye
Care Examination (WEHE)
 Glasgow Integrated Eyecare Scheme (GIES)
 Shipley Ophthalmic Assessment Programme (SOAP)
 Sheffield PCT – trained 19 optometrists detailed evaluation expected in
November/December 2009
Diagram 6: Outcome of Patients Examined Under Welsh Eye Care Initiative
(WECI)
Source: Evaluation of Welsh Eye Care Initiative (WECI)
6.2. Glaucoma Referral Refinement and Ocular Hypertensive Monitoring
 Suspected glaucoma; elevated Intra Ocular Pressures (IOP); or symptoms
observed as part of sight test
 Optometrist with specialist interest; Ophthalmic Medical Practitioner (OMP)
provides service
 Full history and assessment (including diagnostic tests) to establish if
glaucoma or ocular hypertension (OHT) is present
 Co-management (with secondary care) of patients with stable glaucoma
 In community practices with appropriate equipment
 GP or self-referral
Benefits:
 Assessment for glaucoma or OHT is conducted in timely fashion
 Patients retained and managed within primary care where appropriate
 Reduces referrals into secondary care (only 33% of routine glaucoma
referrals from optometrists are found to have glaucoma20 and with new
thresholds for referral in NICE guidance this proportion is likely to be even
less)
 Refines referrals and ensures they are appropriate and timely
 Well received by patients
 Better access and shorter travelling times
34
Issues:
 Providers would need to be appropriately trained, qualified and supervised
to carry out this work in line with NICE guidance
 Providers would need appropriate equipment to carry out diagnosis, in
particular Goldmann Applanation Tonometry (GAT) and only 6 practices in
Wakefield are known to currently have GAT14 and they cost approximately
£900
 Providers would need appropriate IT systems and ability to offer patients
choice of secondary care provider if being referred
 May require supervision from an ophthalmologist
 Secondary Care providers may not wish to release this activity
Examples:
 Manchester (reduction in false positive referrals of 40%)21
 Calderdale and Kirklees LES for Glaucoma Referral Refinement Scheme
(£27.50 fee for each patient for repeating applanation tonometry, fields or
both)22
6.3. Pre and Post Operative Cataract Service
 Suspected cataract
 Participating community optometrists provide service
 Pre-operative service: diagnose cataract; assess impact on lifestyle; risks
and benefits of surgery discussed; self-assessment questionnaire;
suitability for surgery; offers choice of secondary care provider
 Direct listing for secondary care pre-operative assessment and surgery
 Post-operative surgery: final post-operative check up; sight test; discussion
of surgery on second eye (if necessary); routine review
 In community practices with appropriate equipment
 GP or self-referral
Benefits:
 Fewer visits for patients
 Reduces referrals into secondary care by reducing numbers of patients
that do not convert to surgery due to not being appropriate for surgery or
declining surgery on receiving information and discussing risks and
benefits (90+% conversion to surgery compared with 80% previously)12
 Improves quality of referrals into secondary care
 High patient satisfaction
 Better access and shorter travelling times
Issues:
 Participating optometrists will need knowledge of the referral criteria and
risk factors for surgery, included within training and accreditation
arrangements
 Providers would need appropriate IT systems and ability to offer patients
choice of secondary care provider if being referred
 A revised cataract pathway for Wakefield District, including optometrists
providing pre-operative and post-operative care, was previously
35
established (see section 4.6). However, direct listing has not been
implemented and it is not clear to what extent optometrists are undertaking
the range of pre and post-operative functions. Therefore, this may indicate
local resistance to change in this area.
Examples:
 Peterborough have implemented direct listing
 Stockport Cataract Pre and Post-Operative Scheme
36
7. RECOMMENDATIONS AND NEXT STEPS
Recommendations, based on analysis and observations, have been made
throughout this report. They are summarised and categorised in the table
below for NHS WD and Practice Based Commissioners to consider further.
Recommendation
1
Investigate reason for reduction in first to follow-up ratio
2
Outpatient activity broken down by condition is an area that
would require further work. Possibilities include further
analysis of outpatient data, an audit of referrals and
outpatient activity or changes to coding practice.
Undertake work to understand how cataract pathway is
operating and to what extent optometrists are undertaking
pre and post-operative care
Ensure that providers are contractually required to provide
regular reports to NHS WD on complaints, including trend
and theme analysis
Ensure that providers are contractually required to report
SUIs to NHS WD
Explore methods to engage with the public and patients and
find out their expectations and what they want from eye care
services
Explore ways to further raise awareness of Free Choice
among patients, provide information to support patient
choice and encourage GPs and other primary care
clinicians to inform and support patients at the point of
referral
Facilitate direct referrals from optometrists to secondary
care
As service specifications are developed for eye care
services, commissioned pathways should be discussed and
embedded.
Cataracts is the condition which takes up the biggest
proportion of both admitted patient and outpatient care and
is potentially an area where the biggest improvements could
be made.
Improvements in the glaucoma pathway could release
secondary care capacity.
Consider ways to reduce outpatient DNAs across NHS WD
and especially at MYHT
Continued monitoring of provider RTT times and work with
providers to improve performance and deliver a greater
proportion of patient treatments earlier in their pathway
Consider possibilities of greater review/monitoring and
intermediate services within community setting
Refresh cataract pathway to enable optometrists to refer
directly to secondary care, undertake pre-operative care, list
directly with secondary care for surgery, undertake postoperative care
Investigate possibility of installing Choose and Book
software in optometrist practices to enable them to offer
patients choice and refer electronically.
Continue to develop the provider market, in particular
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Type
Understand
Further
Understand
Further
Understand
Further
Quality of
Information
Quality of
Information
Communication
Communication
Service
Improvement
Service
Improvement
Service
Improvement
Service
Improvement
Service
Improvement
Service
Improvement
Service
Improvement
Service
Improvement
Service
Improvement
Market
37
18
providers that can offer additional capacity in local,
accessible settings
Carry out soft market analysis to understand the potential
provider market if NHS WD wished to develop a wider range
of alternative providers
Development
Market
Development
This report will now be shared with stakeholders. NHS WD should work with
Practice Based Commissioners as well as the Local Optometry Committee to
consider and prioritise the recommendations.
38
1
The Operating Framework for the NHS in England 2009/10
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitala
sset/dh_091446.pdf
2
NICE Clinical Guideline 85: Diagnosis and management of chronic open angle glaucoma
and ocular hypertension
http://www.nice.org.uk/nicemedia/pdf/CG85NICEGuideline.pdf
3
A Rapid Health Needs Assessment for Ophthalmology, prepared by Warren Holroyd v4
16/10/2009
This document can provided by Public Health Intelligence & Capacity Building Team or
Planned Care Commissioning Team. The document should be circulated with this report.
4
ONS/Dr Foster/JSNA, WDNHS (2008), p28
ONS. (2009). Spreadsheet accessed on request: Wakefield LSOA Single Year Estimates.
Accessed 25/08/09. Available via request to the Office of National Statistics.
WDNHS. (2008). Developing Healthier Communities - Joint Strategic Needs Assessment for
Wakefield 2008. Accessed 19/08/09. Available via the Intranet at: http://nww.wdpct.nhs.uk/
5
NEHEM. (2009). Website: National Eye Health Epidemiological Model. Accessed 19/08/09.
Available via the World Wide Web at: http://www.eyehealthmodel.org.uk
6
Draft Service Specification for the Provision of a Diabetic Retinopathy Screening Service
between NHS WD and WDCHCS
7
DH Tariff Information: confirmation of Payment by Results (PbR) arrangements for 2009-10
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_0
94091
8
General Ophthalmic Services: Activity Statistics for England and Wales, Year Ending 31
March 2009
http://www.ic.nhs.uk/pubs/gosactivity0809p2
9
Future Sight Loss UK (1): The economic impact of partial sight and blindness in the UK adult
population
http://www.vision2020uk.org.uk/ukvisionstrategy/page.asp?section=74
10
NHS Constitution for England
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidanc
e/DH_093419
11
National Eye Care Services Steering Group First Report (2004)
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitala
sset/dh_4080999.pdf
12
Commissioning Toolkit for Community Based Eye Care Services
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitala
sset/dh_063958.pdf
13
General Ophthalmic Services: Workforce Statistics for England and Wales, 31 December
2008
http://www.ic.nhs.uk/statistics-and-data-collections/primary-care/eye-care/general-ophthalmicservices:-workforce-statistics-for-england-and-wales-31-december-2008
14
NHS Wakefield District Briefing Paper – NICE Guidance and Ocular Hypertension
39
15
The Year 2008/09
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_0
99700.pdf
16
LOC Support Unit Guides
http://www.loc-net.org.uk/locsu/index.html
17
Our Health, Our Care, Our Say
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidanc
e/DH_4127453
18
High Quality Care for All
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitala
sset/dh_085828.pdf
19
PEARS scheme evaluations:
Welsh Eye Care Initiative (WECI) Full Evaluation
http://www.wales.nhs.uk/sites3/Documents/562/MASTER%20BLASTER%20DOCvJW.pdf
Glasgow Integrated Eyecare Scheme (GIES) and Shipley Ophthalmic Assessment
Programme (SOAP) findings quoted in:
Commissioning Toolkit for Community Based Eye Care Services
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitala
sset/dh_063958.pdf
20
Vernon SA, Ghosh G, Eye (2001) 15, pp458-463
21
DB Henson, AF Spencer, R Harper and EJ Cadman, Community refinement of glaucoma
referrals Eye (2003) 17, pp21-26
22
Local Enhanced Service Agreement for Glaucoma Referral Refinement Scheme in
Calderdale and Kirklees
40