York Racecourse was the venue for the recent RNIB/Department of Health (DoH) conference 'Delivering The Vision' at which the outcomes of a number of eye care pathway pilot programmes were to be discussed.
Coming just a week after the BBC 2 documentary Can Sir Gerry Robinson save the NHS? I was fascinated to see if the challenges of NHS bureaucracy were quite as they were portrayed by the BBC, I also wondered if the series had shocked others as much as it shocked me. I didn't have to wait long for an answer - the first question of the day referred back to Sir Gerry's challenges of getting different groups to work differently and didn't produce a confidence-inspiring answer.
The conference was opened by Anita Lightstone, head of service development and research at the RNIB and Andrew Kent, director of the NHS Eyecare Services Programme. They reminded delegates of the origins of the pilot when, in 2004, a number of schemes were launched to look at shifting care from the secondary to the primary sector, concentrating on AMD, glaucoma and low-vision services. Cataract schemes, also specified, were already moving forward in this area.
Kent outlined the principal objectives of the pathway schemes as being:
? To develop innovative approaches and partnerships
? Remove barriers
? Increase access locally
? Increase awareness of the importance of eye health
? Engage and make better use of professionals.
He also emphasised the criticality of putting the patient at the centre of the change.
It was also emphasised that having fewer primary care trusts (PCTs), each with a larger area, should help with the rolling out of schemes.
Stakeholders
Richard Smith, vice-president of the Royal College of Ophthalmologists, then took us through a presentation on the subject of engaging stakeholders in change. Smith outlined a model for change which covered three key stages - 'Why change?' 'What are we changing?' and 'Who needs to be involved?'
Change was needed to ensure schemes were standardised, could adapt to a changing environment and, indeed, to ensure cost efficiency. Smith then used the example of one glaucoma pilot scheme to illustrate some important points:
? Keep any change people-focused
? Beware of generalisations and assumptions
? Promote lifelong learning and keep communicating
? Recognise NHS funding processes must be changed if we are to make significant change going forward.
Lesley-Ann Alexander, chief executive of the RNIB, then spoke on keeping users at the heart of service design and delivery. She emphasised that it is absolutely critical that organisations listen intently to their users. She pointed out that successful private companies do this as a matter of course. She also reminded the audience that listening to customer feedback is not always comfortable and that 'you might not like what they tell you but it is essential to listen and listen hard to the quiet voices'. Alexander then took us through an excellent example of how a small book club within the RNIB became empowered to grow into what is now eight such clubs significantly enhancing the quality of people's lives.
Glaucoma
I then attended a breakout session which looked at the glaucoma shared care scheme in East Devon. Dan Byles, the ophthalmologist in charge, took us through the set up of the scheme including the recruitment of local optometrists through the local LOC and the training involved. He outlined the key findings as:
? Shared care for glaucoma can work in a rural community
? A community scheme needs a strong in-house element to ensure consistency and governance
? Practitioners need to be seeing at least 10 patients per month
? Need for good training courses is essential.
It was this last point which exercised my discussion group with a consensus that the optometry profession should define core competencies consistently for involvement in shared care schemes which would then enable CET providers to support the upskilling of optometrists in a very cost effective manner.
Government view
Keynote speaker at the conference was Rosie Winterton, Minister of State for Health Services. Winterton outlined the achievements of eye care over recent years, highlighting the reduction in cataract waiting times and the reintroduction of free eye examinations for the over-60s. Although it was an understandable exhortation of government policy I also sensed a genuine recognition by the minister that how we deliver primary eye care is an exemplar for healthcare delivery - a recognition that the eye examination offers consumers a wide choice of locally accessible providers delivering a good service at a competitive price.
Winterton also reminded delegates that by 2020 the over-65 age group will have increased by a third and therefore it was important that we maintain the momentum of the eye care pathways initiative. It is clear that this government sees the transfer of care from the secondary to primary sector as the way forward.
Winterton then announced that the government was today giving PCTs the freedom to make local arrangements for the provision of community-based eye care schemes and was launching a toolkit to enable them to do so. This stopped short of telling PCTs they must set up schemes and, not surprisingly, there would be no new money for this work.
The final speaker for the day was Richard Clarke, head of the Partnership and Delivery Unit for the Third Sector. Richard gave an entertaining presentation on how the Third Sector - namely voluntary and charity organisations - are seen by government as having a key role in closing the rhetoric-reality gap that exists between policy and practice.
Commissioning schemes
Day two started with a very good presentation by John Hearnshaw, primary care specialist adviser for optometry, who looked at new approaches to commissioning services locally by PCTs. He highlighted that the DoH was publishing a number of new documents in this area, covering a review of the pilot schemes and also the commissioning of programmes going forward (these will be available on the DoH website). He emphasised that commissioning managers will need to balance the need for competitive tenders with the prerequisite of making it attractive enough for suppliers to bid for the work, and that no national tariffs will be imposed.
Hearnshaw also made it clear that, if the government is to hit its overarching target of a maximum 18-week wait from GP referral to consultant, many current processes will need to be radically different.
Anne Bristow, chair of the Association of Directors of Social Services Sensory Sevices Sub-Committee, emphasised the need to improve the capability to work across traditional boundaries in this area and that only by the various professional stakeholders working together could this project succeed.
I then saw how well this could work by visiting the low vision workshop hosted by Gateshead PCT. Gateshead have set up a successful programme by involving optometrists and social workers to improve the provision of support in the community for their low-vision population. The key to this was the low-vision assessment and visual rehabilitation investigation being done in one appointment.
Sue Coulson, of Gateshead PCT, gave some fascinating insights into how, when all of the stakeholders are engaged and the patient needs are understood, a community-based programme can be a success. They have now received approval to move from pilot to a permanent programme.
Education
After lunch Bryony Pawinska, chief executive of the College of Optometrists, delivered a presentation on the issues around education training and audit. Pawinska highlighted the recent changes in Scotland as an example of how easily the optometry profession can be upskilled to provide a higher degree of patient care. She also outlined the proposed process for the development of specialisms, whereby the GOC defines the competencies and the College manages the candidates through assessment.
How have the schemes fared?
We then had a presentation on the 'Key Learnings from the Pilot Scheme' based on both quantitative and qualitative feedback and listening to people involved in the programmes. Surprisingly, the only patient feedback was through staff involved in the programmes.
While the report highlighted that the schemes were variable in their progress and that the time needed to change behaviours was often underestimated, I have to say I was disappointed with this presentation. I did not see any quantitative data, any insights as to what made the successful programmes work and how they could share their learnings with others. More worryingly, I think the lack of any patient satisfaction monitor gave me little confidence that the very well articulated message from Lesley Alexander the previous day about the need to listen closely to the consumer, the way private sector companies do, was really happening.
Finally Bob Ricketts, head of Demand-Side Reform at the DoH, gave a very good presentation on the future of eye care delivery which emphasised the following points:
? Demand - we need to innovate to meet patient need and make better use of the skills base in eye care
? Reform - increased choice for the patient and increased financial flexibility to move the NHS money to where it needs to be. Commissioning managers need to be more accountable for their PCT area
? Principle of local commissioning as a large part of the health agenda currently.
At this point, the conference was abruptly cancelled due to the worsening storms and the need for delegates to start to make arrangements to travel. I hope the cancellation and lack of final outcome don't prove to be prophetic. It will be a real shame if the good intentions of this conference, like many of the delegates, are left stranded in York.
There seems to be a genuine desire within the DoH to press on with this reform of eye care services, and also a genuine recognition for the way in which eye care is delivered. The messages about keeping the patient at the heart of delivery and working across professional boundaries lie at the heart of successful delivery. However, making that happen consistently could be challenging. I wonder if Sir Gerry Robinson has anything in his diary for 2007? ?
? Richard Edward is head of professional resource & development, Boots Opticians