writes Elizabeth Frost, chair of the Cataract Steering Group
The cataract patient pathway initiative is proving to be a bonus for many elderly and susceptible people and deserves a higher profile,
writes Elizabeth Frost, chair of the Cataract Steering Group
One of the initial pieces of work for the Eye Care Services Steering Group was to set up working groups to look at improving patient pathways for four conditions: cataracts, glaucoma, low vision and AMD.
I was asked to chair the cataracts group, and the membership was drawn from a wide range of disciplines. There were representatives from optometry and dispensing optics, ophthalmology and general medicine, the regulatory and representative bodies, patient interest groups, and the Department of Health. The group worked mainly by e-mail and phone, with a few meetings between individuals.
I produced an outline pathway, based very much on the work of Action on Cataracts and the evidence that was available from areas where the suggestions in that document had been piloted. Input was then invited from the committee members and incorporated. The draft pathway was presented to the
Eye Care Services Steering Group, and further modified. The pathways were presented at a series of DoH roadshows in April and May 2004. The Cataracts Pathway has now been circulated to PCTs as commissioning guidance.
The Traditional Pathway
Cataract patient pathways have been gradually evolving over several years and many areas have been working to make them more 'patient friendly'. However, there were still some places where this had not happened. In these areas the patients, who are mainly elderly, still had a long and tortuous journey.
It often started at the GP, where the patient mentioned that they were not seeing so clearly. The GP might suggest that it could be cataract and they would be directed to the optometrist/ophthalmic medical practitioner (OMP) for a sight test where it was found that the cause of their problem was cataract.
As a result they might have a new pair of spectacles to help them until they were able to have surgery, and a referral letter was sent to the GP.
Back the patient went to their GP, who would probably mutter, 'Hmm, cataract, just as I thought,' and refer them to the local hospital eye unit.
The letter would be received at the eye unit where the referrals were prioritised. Cataract patients would be called for a routine 'in turn' outpatient appointment. But this could take many months.
At the outpatient appointment, the patient would be assessed, and a cataract found. This would hardly be a surprise to the patients - it could have been mentioned to them at the three previous steps in the pathway. However, if asked why they were at the hospital, a fair number would not really know. Patients often have very little idea of what a cataract is - some are under the impression that it is a 'growth' in the eye. Others, once they were told what a cataract is and how it is likely to affect their vision, and the options for surgery, decided that their vision was not sufficiently badly affected for them to want surgery, or at least not yet. Some of these would be retained by the hospital, and reassessed in a year's time to see if they were yet ready to be put on the list for surgery, while others were discharged. Those who were suitable for, and wanted surgery, were put on the waiting list. Once they reached the appropriate place in the waiting list, they would be called to another outpatient appointment for confirmation that they still wanted surgery and that it was appropriate, and to have biometry and other pre-operative assessment. Surgery would follow within a few weeks. For the majority of those undergoing surgery, it would be as a day case under local anaesthetic, and they would return home after a few hours. In many cases the patients returned to the hospital after 24 or 48 hours for a post-op check, and then again at four to eight weeks for a final check of the wound and to check the VAs. After that, the patient would return to their optometrist/OMP for refraction and spectacles. What a long and complicated pathway this is and certainly not very patient friendly.
The Revised Pathway
The aim of the new pathway is to ensure that the patient is given the appropriate information so that they understand the issues and are able to make an informed decision about how to address the problem. Once this has occurred, they should be able to have any treatment as soon as possible. It is also the Government's declared intention to transfer healthcare from the secondary to the primary care setting where this is appropriate, and to make better use of the qualified personnel available. To facilitate this, the revised pathway enables the diagnosis of the cataract and initial patient work-up to be made by the community optometrist/OMP.
Where the optometrist/OMP feels that the cataract is interfering with the person's daily living skills, such as problems with driving or walking outdoors on bright days, or making reading difficult, the optometrist/OMP undertakes the next steps. These would include discussing with the patient what a cataract is and how it is likely to affect their vision over time. They would also tell the patient about the processes involved in cataract surgery, and discuss the general risks and benefits. If the patient then decides that they would like to have surgery, the optometrist/OMP would complete a referral form and the patient would be referred directly to the hospital and a copy of the referral form sent to their GP. They would also give the patient information leaflets about cataracts and surgery, and, if appropriate, the contact details of organisations that could give them practical help and support through the process.
This means that the patient is referred to the hospital with a diagnosed cataract that is interfering with their lifestyle; they also know what is involved in cataract surgery, and have made an informed decision that they would like to have surgery. The patient should also be given a date for their hospital outpatient appointment. At that visit they would see the ophthalmologist for confirmation that cataract surgery is appropriate, and to discuss with them their individual risks. They would also have their biometry and be told about procedures on the day of surgery. The surgery should then follow within three months.
After surgery, the patient should be returned to the care of their community practitioner as soon as possible. There are several options for the 24/48-hour postoperative check. It could be back at the hospital by a doctor or optometrist; undertaken by the local optometrist/OMP in their practice; or by means of a telephone check by an ophthalmic nurse.
The final check and refraction would take place back in the optometrist/OMP practice, with a report giving final refraction, VA, and confirmation of wound healing sent to the hospital for audit.
Where appropriate, the second eye would be discussed, and advice given about how this would be managed. Fast-track re-referral arrangements would be set up to deal with postoperative problems.
During the time that the Cataract Patient Pathway was being developed, the Modernisation Agency was beginning to pilot 'choice'. Since this was starting with cataract surgery, the pathway was adapted to include choice of provider at the point of referral by the optometrist/OMP. The choice could either be offered directly by the referrer, or via a local choice booking agency. The patients should be given basic information about the different service providers, and be able to agree their outpatient appointments.
This pathway is designed to reduce the number of steps and repetition for the patient, shorten the time from the sight test to surgery, and give them the choice of where they have the operation. It should free up a large number of outpatient appointments, not only by reducing the number of times that each patient who has surgery attends, but also ensuring that only those who want and are suitable for surgery have appointments.
This increases the amount of work for the community optometrists/OMPs. This extra work is outside the GOS sight test, and so needs to be funded. This has proved to be a thorny issue - the PCTs have to find the money as the work cannot be funded from the non-cash-limited GOS budget.
Issues raised
At the DoH roadshows where the chairs of working groups presented their pathways, there were workshops to discuss them. Following these presentations, I have been involved in meetings with commissioners and others in several PCT areas.
The main points raised and questions asked have been similar. There is general agreement that, where it has not already been done, the patient pathway should be revised as reflected in the commissioning guidance. The major issue is funding. Money given to the PCTs is not ring-fenced, they have a large list of 'priorities', and this is not necessarily one of them. There is still some misunderstanding about how optical practices are funded, both by commissioners and our medical colleagues. This can make meaningful negotiations difficult and frustrating.
Another issue is the training of future ophthalmologists; they need to see a number of normal post-op cataract patients. This can be addressed by undertaking the initial check for a proportion of patients in the hospital.
There have been mixed views expressed about the GP not initiating the hospital referral. In some areas the GPs are happy about this, but in others either the GPs or the ophthalmologists have felt that vital information may be missed. However, it was generally agreed that sending the referral via the GP did not add value to the referral, but did increase the length of the pathway. Information about any medication could be requested by the referring optometrist/OMP, and the patient asked to bring their medicines or prescriptions to their outpatient appointment. A copy of the referral form is also sent to the patient's GP so they have an opportunity to provide any information that they feel is appropriate.
The current position
There is considerable pressure on PCTs to offer choice at the point of referral to cataract patients. In some areas getting this in place quickly has taken priority over developing the recommended pathway, which is a pity as the opportunity to make a real difference to the patient experience has not been taken.
Many optical practices do not have computers or fax machines, making it difficult for them to book patients into hospital clinics. This is another funding issue, and one reason why some areas are using a patient booking centre. The funding for the extra services of optometrists/OMPs has not yet been resolved. In several areas it is provided as part of a pilot study for a set time. Only time will tell whether the monies for ongoing services will be forthcoming.
The relationships between the professionals involved in this pathway are changing. Many ophthalmologists are welcoming the direct referrals and appreciating the skills that the optometrists have, although some express suspicion that they will over-refer if they are paid a fee.
However, with future funding following the patient, some are also keen to develop good relationships with their local optometrist/OMP colleagues so that they will receive appropriate referrals and keep the funding for their services.
I hope that the cataract pathway will come to be widely adopted nationally, so that patients have a swift and accessible service of a high standard, in a convenient location, and appropriate use is made of the available professionals.
<25C6> Elizabeth Frost is a director of the Association of Optometrists