Frustration is mounting among high street practitioners and doctors alike as the postcode lottery of commissioning eye care services stands in the way of better patient care.
The Royal College of Ophthalmologists’ president Professor Carrie MacEwen authored an article for the BBC’s Scrubbing Up online slot (bbc.in/1YZeddT) and appeared on BBC Breakfast TV last week.
In the article she pointed out that hospital attendances are growing year-on-year in the UK, with 10% of them eye related. There had been an increase of up to 30% in eye clinic attendances over the past five years, meaning the pressure building up in ophthalmic services could no longer be ignored.
‘Common eye conditions which were previously untreatable, such as age-related macular degeneration, can now be treated successfully, but this adds to the demand on eye clinics. Efforts to create more care in the community show no evidence of an actual reduction in demand in hospitals,’ said Professor MacEwen.
Her comments drew an immediate response from the optical profession, as Locsu and the Optical Confederation called on clinical commissioning groups (CCGs) to end the eye care postcode lottery by commissioning community services.
Managing director of Locsu Katrina Venerus said: ‘For too long, optical practices have been overlooked as part of delivering a reformed and preventative NHS. But optical professionals have the skills and locations and the determination to play a part in delivering better eye health and reduce levels of preventable blindness. CCGs need to wake up to this and realise community services are a cost-effective solution.’
The College of Optometrists commented on the efforts to support under-resourced services. New College president Dr Mary-Ann Sherratt said: ‘Optometrists working in community settings can help alleviate the pressure being experienced in hospital eye departments but service organisation and provision will need to incorporate a range of professions working together, and be different, depending on the locality. We are working closely with the Royal College of Ophthalmologists, and other organisations in the sector through the Clinical Council for Eye Health Commissioning, to develop different service models for CCGs to commission the best services for the patients in their areas, and to ensure that optometrists are able to do more within their skill set.
However, for new solutions to be sustainable, optometrists in the community must be connected electronically to the rest of the NHS, to allow swift referral and communication between experts. Improved IT systems will also enable better data collection, so that new services can be monitored for cost-effectiveness and improved as time goes on.’
There was only a brief mention of optometrists in Professor MacEwen’s warning, when they were noted alongside ophthalmic nurses and orthoptists as being part of the potential solution.
Distorted priorities
Within hospitals, she explained, targets have been introduced to ensure patients avoid long waits before receiving hospital treatment. But the targets applied to new patient referrals, and the system was accused of distorting clinical priorities.
Professor MacEwen added: ‘The reality is that increasing demand for eye clinic appointments comes from patients with chronic eye diseases, such as macular degeneration, glaucoma and diabetic eye disease. These patients are the most vulnerable and at the greatest risk of irreversible loss of vision. These conditions require long-term “return” or “follow-up” appointments for repeat monitoring and regular treatment procedures.
‘These follow-up appointments are more likely to be postponed or simply be lost in the system for months, and sometimes years, to accommodate new referrals in already oversubscribed clinics.’
Data for follow-up patients was not routinely gathered ‘making it impossible to determine the magnitude of this problem’, she added. Reports had found ‘unsafe delays to ophthalmic follow up in clinics causing serious incidents and harm’ and the RCO was to carry out its own national study into follow up delays.
Meanwhile, optical sector representatives have repeatedly emphasised the sector’s willingness to reduce hospital pressures by taking on more high street services.
Locsu and the Optical Confederation last week urged CCGs to introduce more high-street eye health services following the revelations that hospital ophthalmology services are at bursting point.
Venerus added: ‘Professor MacEwen is right to draw attention the severe pressure hospital eye clinics are under. A major part of the solution – already set out in the NHS Five Year Forward View – is to expand services by transferring more routine and step-down care into community optical practices.
‘We are already supporting optometrists in a number of areas to work with ophthalmologists in acute trusts on initiatives to help address capacity problems. But we need all CCGs to put patients’ sight at the top of their health agenda and commission appropriate local services to ease severe bottlenecks.
‘There are over 10,000 optometrists in high streets across England that can be utilised to monitor low-risk patients in the community. Local studies show that on average, this could take up to one-third of patients at risk off waiting lists and allow ophthalmologists to concentrate on the most urgent cases and follow-up appointments.’
Venerus also urged the NHS to connect optical practices to its IT systems, such as the e-Referral Service.
Inadequate resources
Concern was also expressed by the Macular Society, which cited inadequate NHS resource to deal with the demand for wet AMD treatments. A spokesperson pointed out that drugs had to be given promptly because they worked best on new, immature blood vessels and once the blood vessels have matured or the macula becomes scarred the drugs do not work as well. The same was true for people with diabetic macular disease and retinal vein blockages.
Macular Society chief executive Cathy Yelf said: ‘Delays in eye clinics cause sight loss. We know many patients have lost vision because not enough resource has been put into wet AMD services and some hospitals have been very slow to adopt new working practices such as using nurses to give injections. There are not enough doctors to deliver the service.
‘Patients get very frightened and anxious when their appointments are delayed because they know the consequences. Some have been so anxious we have referred them to our counselling service. We understand that the NHS is under great pressure but some clinics appear to manage better than others. It is a tragedy that people lose sight when there is a treatment out there that will help keep their vision for longer but it is not given in time.’
Reasons for delays included shortages of qualified staff, lack of facilities such as clean rooms, inadequate levels of commissioning and slowness to use new ways of working, including training nurses to deliver injections, according to the charity.
The health cost of missing follow-up target goes beyond eye care and can lead to further strain on the NHS.
Professor MacEwen added: ‘Solutions may be seen as difficult, but include working to protocols and guidelines to optimise efficient care; utilising the expanded skills and roles of ophthalmic nurses, optometrists and orthoptists; increasing networks between primary and secondary care and educating and empowering patients.’
Maybe the answer is simpler than that, with clinically trained high street practitioners (see panel) already lobbying to take on extra capacity and make waiting list warnings an issue of the past.
Optometry the solution
A Devon MP was told last week that 37,000 GP appointments a year could be freed up across the county if primary care opticians were used to triage, manage and prioritise patients who would otherwise visit their GP or turn up at A&E.
The message was delivered by Specsavers Okehampton’s Kath Dandy, who briefed MP Mel Stride (both pictured above) on how the sector was well placed to treat minor eye conditions and could save the NHS locally £450,000 a year in the process.
The Central Devon MP also met Jonathan Drew from the Local Optical Committee and Jenny Gowen, head of public affairs at the Optical Confederation.
Stride added: ‘The arguments put forward by the opticians today were very compelling. If people can get a better service, closer to home and if the number of people making GP appointments and visiting A&Es with minor eye conditions is reduced as a result, then the proposals I heard today are worth serious consideration.’
Case study: wet AMD
A patient contacted the Macular Society helpline for support having been diagnosed with wet AMD in one eye late last year. He was told his acuity was too good for treatment, being 6/10, but a week later it had dropped to 6/18 – below the legal driving limit. However, he was told he would not get an injection for four weeks. A week later he was told the same thing. This made him so anxious that after another two weeks he paid for three Avastin injections privately, despite not having medical insurance.
There have since been further delays in readmitting him to the NHS system for follow up Eylea treatment and only his own persistence and the direct support of the Macular Society has ensured he has had his injection.
‘We all realise that other people have been pushed down the list as a result. However, the patient’s vision in the affected eye has not recovered and is now considering having to close down his business which involves him driving a public service vehicle; his sight is now too bad for him to keep his licence,’ a spokesperson for Macular Society added.
