Getting hospitals and the high street to work together to manage eye conditions such as cataract, glaucoma and age-related macular degeneration has long been a dream thwarted by lack of leadership, a fragmented NHS and absence of political will.
At Optrafair Newmedica and Locsu signed an agreement on a post-cataract (News 20.04.18) framework for community optometrists which they say can form the basis of an England-wide model for a range of conditions.
The partners say the agreement would create a model to take to government which could create the elusive blueprint for community ophthalmology. Although the agreement covers cataract services Richard Whittington, chief operating officer of Locsu, says that it can form a basis for other treatments.
‘What we have got is two competing crises within NHS eye services,’ he says. ‘There is a capacity crisis in the acute sector, where they can’t manage the capacity that’s there already, but we’ve still got patients flooding in. This is creating waiting lists but also creating a system which is unsustainable and actually quite dangerous. We also have commissioners in some areas who are reticent to commission solutions. What we have to define is a pathway which is inclusive for all areas of acute care, community care and private care. It doesn’t matter if you are a multiple or an independent, whether you are Specsavers is irrelevant. It’s about being able to deliver. If we can show that, then we are going to be able to persuade the commissioners, the CCG, the trusts or anybody else.’
Specsavers involvement started with Newmedica when it took a stake in the firm in 2016. A stake which Specsavers’ founder, Doug Perkins says, was made for the benefit of the whole sector and not just for Specsavers. Giles Edmonds, clinical services director for Specsavers says the time has come to lead by example.
‘Over the past couple of years, as a profession, we have made some progress in terms of upskilling and accreditation but it’s fair to say that hasn’t been fast enough as we need to make as a profession. Disruptive change is still happening around us. That’s going to continue whether it be technology or social aspects, the economic or political situations. The barriers to change are still there whether that’s NHS England commissioning or the lack of coordinated leadership across the profession. We don’t have a strong model of community optometry that we can take to government.’
He did not think there was a belief within some of the lead organisations that optometry could deliver the cost savings required. He says: ‘Those cost savings are fundamental for us to be able to push back against the Royal College of Ophthalmologists.’ He adds, despite various reports, the College has still not fully engaged with optometry in ophthalmology pathways.
It is not just about creating the models says Nigel Kirkpatrick, consultant ophthalmologist and Newmedica clinical director: ‘It’s about creating that operational platform that allows you to add in other things. Once you have a flow of patients going back for their post-op you know that the dataflows work, that the IT is there, that the pathways are there and the nodes are connected. Once you have all of that it becomes a whole lot easier to add in AMD, so let’s do the simple one first, show that it works, create those pipes and then we add in more complex things afterwards.’
Nigel Kirkpatrick, consultant ophthalmologist and Newmedica clinical director
Darshak Shah, Newmedica MD, highlights the scale of the problem by pointing out that 30% of what is going through the hospital eye service is not being followed up – a situation Whittington describes as ‘lunacy’. ‘Those patients just tend to get pushed back time and time again,’ says Shah.
As the service takes in new patients and organises new surgeries those original patients are just delayed and delayed. And some of them come to harm. ‘For 15 years this has been flagged up as a problem and solutions have been put out there but there’s not much practical change. We in the Newmedica world think that we can help optometry to deliver care for chronic disease patients.’
Whittington paints a grim picture of a ‘bow wave’ of a backlog which is growing and growing. ‘We have glaucoma patients who haven’t been recalled for 10 years and everyday a patchy structure of commissioning of primary care services is just adding to that wave. As someone who used to work in hospitals I am very aware of how big that bow wave is. If patients go to Newmedica they don’t add to that bow wave. They go in, they have their procedure and they come out again.’
Whittington is keen to stress the agreement is for all practices, not just Specsavers and says practical considerations such as tariffs and getting patients back, post-op, have been taken into account. ‘What has been announced is an agreement for a framework around cataract whereby if Newmedica does the surgery the post-op follow up will get delivered in practice in the community under a national framework agreement. ‘We have a single process for referring in and single process for referring out. It doesn’t matter at that point whether you live in Newquay or Newcastle the process is the same.’
These are all NHS funded services, says Kirkpatrick: ‘New- medica will be contracted by CCGs in various parts of the country to deliver ophthalmological services and those will include cataract. Where we deliver cataract surgery for the CCG under the NHS, free at the point of use, we will then enable those patients to go back to their originating practice to have their post-op care.’
At the moment Newmedica has three units in Bristol, Gloucester-shire and Lincolnshire and is about to launch a fourth in Leeds. A national roll out plan will follow with the current three areas acting as a proof of concept.
Kirkpatrick says care can now be offered to more than just the people in those areas. ‘If you live in Somerset and your local hospital has a long waiting list our service is accessible and you are allowed to be referred in so we are offering choice to a wider group of patients today.’
Having a single system is one of the goals of the agreement says Whittington. ‘The agreement is between Newmedica and the local Primary Eyecare Company but we have agreed a framework between Newmedica and Locsu that that agreement is always going to be the same.’ He says the important thing is that the PECs are governed and only exist because of a memorandum of understanding from the LOCs and every practice is a member of the LOC so every practice gets the same access and the same opportunity at the same tariff. ‘It includes everybody so long as they are accredited. As Newmedica we can’t exist purely to deliver care to Specsavers patients,’ says Darshak.
Darshak Shah, Newmedica MD
All practices have patients with eye conditions and we will deliver services to them all notwithstanding the arrangement the firm has with Specsavers. ‘The only way to be a comprehensive, equitable eye care provider is to have this kind of relationship in place with the whole sector.’
The next hurdle is convincing commissioners and the government agrees Kirkpatrick. ‘I think some of that is around demonstrating and convincing.’ He says from his observation of working in the sector is that the solutions put forward by NHS England, the optometry sector working by themselves or Royal College of Ophthalmologists or NICE has had some bias towards their own constraints. ‘What we are doing is ignoring those constraints and designing something that works and bring the two ends of the profession together and roll it out.’ He says Newmedica has plans for six or seven new centres this year and the same the year after that. ‘If we wait for NHS England to pronounce what the right models is we will wait another 10 or 15 years and we’ll be drowned by this wave.’
In the meantime the duo have to continue to work within NHS England’s constrains. There is no simple, national model for developing contracts with CCG so they will have to be negotiated on a local level. ‘That’s one of the frustrations and the problem of a system where you have 208 commissioners,’ says Kirkpatrick. ‘There are 200 and something ways they choose to commission, in some CCGs there is a tender, in some AQP [any qualified provider], there is no consistency.’
As an example Darshak points to the system in Gloucestershire which uses a scoring system for cataract which is unique and is contrary to current NICE guidelines. ‘I can see why they have done it,’ but, he concludes: ‘It’s a postcode lottery.’
Whittington says the agreement also has to be robust enough to withstand that postcode lottery. ‘The model is sound and the PECs can absorb the activity but what we are doing is consolidating the PECs so what were quite small local organisations are now much bigger regional organisations. The point of that is to give credibility and to give commissioners financial security but it also gives robustness.’
Any independents tiptoeing around a deal they see as a Specsavers initiative should get involved, says Whittington. ‘For me there are three things that practices need to do. They have to get involved in their LOC, once they are involved with their LOC get involved with their PEC and if they are not accredited to deliver the services that are there they need to get accredited. Once we have an accredited workforce these agreements will come much easier.’ From a Locsu perspective this isn’t about a tie up between, Newmedica and Specsavers practices. This is about Newmedica and the whole of the sector via the PECs,’ says Whittington.
The big win is taking work away from the secondary sector and bringing it back into the community. Each year over 330,000 cataract operations are conducted. Immediately that takes a third of a million appointments out of NHS hospitals, says Whittington. ‘Think what difference that would make to that bow wave.’
Edmonds paraphrasing Specsavers founder Doug Perkins says the tie up with Newmedica has been for the sector’s benefit. ‘This is a completely agnostic approach in that someone has got to lead the change. If Doug didn’t invest that money we couldn’t see anyone else leading that change. This was a way of saying if no one else is going to do it we are just going to have to help the sector.’
As a former director of a CCG Whittington says the power of ready-made solutions shouldn’t be overlooked. CCGs are under pressure from all sides so it falls to the sectors to come up with workable solutions and take them forward to the CCGs. ‘If someone comes to you with a solution that works you say yes.’