‘I think the public is unaware of what is possible,’ says Andy Willcocks, hospital director at Optegra in Guildford.
Optegra’s cool, calm air-conditioned environment is a welcome respite from the heatwave but it is also purposefully created by the specialist eye hospital group to enhance the experience of patients. Optegra prides itself on ‘just doing eyes’ and since opening (See Optician 05.09.08) it has carried out 8,700 general ophthalmology procedures along with 9,000 cataract surgeries and 2,240 refractive lens exchanges in Surrey alone. It is intraocular lens surgery that Willcocks refers to in his opening comment and it is a procedure he is excited about both as a refractive corrective option (refractive lens exchange) and for cataract patients (refractive cataract surgery).
The hospital group carries out NHS work and sees private patients for a range of ophthalmological treatments. When it comes to cataract the private patients get more time, because that is what they have paid for, but crucially they also get a wider choice of intraocular lens (IOL) options. Optegra is on a mission to engage with optometrists and GPs to get them to impress on the public the choices that are now available post cataract and for refractive correction.
Willcocks, a nurse by profession, has a long association with refractive surgery and was involved in setting up a clinic in Bluewater 15 years ago. ‘Coming back 15 years later I can see how much has changed,’ he says. ‘The thing that excited me about intraocular lens surgery is if someone is coming in for cataract surgery we can say, “shall we correct your prescription too?”’.
A crucial element in the patient journey is how they get information on what procedures are possible, their suitability, the outcomes and the financial implications, and NHS structures can make that difficult. What Optegra wants to do is engage with primary care and provide optical professionals with the right information to educate their patients.
He says on diagnosis many patients will be referred and embark on a process through the NHS resulting in a monofocal IOL not realising that other options are open to them. ‘This is why the optometrist is crucial at advising patients on their options as early in the process as possible. The patient might not realise that they can get other things.’
‘I think we have got to get out in the community more than we have been to keep them [optoms] up to speed with what is on offer.’ He says all the private referrals will come through optometrists and GPs and all patients will have seen those practitioners at some point. ‘They are the cornerstone of what we do.’
Willcocks sees some exciting growth in the patients coming through. He says people are not prepared to put up with poor eyesight and says many private patients come through because they feel their vision has to get very bad before they will be treated on the NHS. Others may be early onset cataracts, those with private health insurance or older people. ‘People aren’t putting up with poor vision in their retirement and that’s a good thing.’
‘We are quite pro-active here,’ says consultant ophthalmic surgeon Dan Lindfield (pictured) describing a regular series of educational events held for GPs and optometrists. He says topics might be about using an OCT, glaucoma, or the latest intraocular lens technology.’ It is opening the door to let everyone know what is happening. He says winning the ‘hearts and minds’ of optometrists through a collaborative approach makes for better informed practitioners who can impart that knowledge onto their patients. ‘We are trying to make sure early diagnosis is taking place,’ for conditions such as glaucoma but making sure patients are aware of the options when it comes to refractive and cataract lens replacement.
He is effusive about refractive lens surgery which he sees as a breakthrough both for refractive correction and in cataract. He says refractive cataract surgery is blurring the boundaries now surgeons are happy with the IOL lens technologies especially for younger patients suffering early onset cataracts.
Patients may have worn glasses all their lives but have the opportunity, with a corrective IOL, to have their cataract removed and benefit from good vision at all distances. Younger people may be easier to operate on, they may find it more affordable and they have more of their life left to enjoy the lens, he says.
Rory Passmore, UK managing director says the rapidly changing environment in eye care makes Optegra’s educational events invaluable and enables optometrists to get crucial messages across to their patients. He says he can be surprised by a relative lack of knowledge when it comes to some laser techniques and wants Optegra to support optometrists in filling that gap.
He also agrees that health service structures can complicate things and make patient choice tricky. ‘Our big thing at the moment is to make patients aware of the choices around cataract.’ While his private patients have a choice of advanced technology lenses Optegra has agreed with the NHS which lenses will be used on its patients.
Lindfield says a surgeon under the NHS faces an ethical dilemma. The NHS does not allow multifocal or premium lens options. Patients cannot be ethically ‘traded up’ to a premium lens, even if it may be more suited to their lifestyle. Promoting private healthcare within a NHS environment is against a doctors ethical code.
However, he also has a duty of care to ensure that patients know that multifocal and extended depth of focus IOLs are possible. He feels ‘a lens discussion is much better performed by the optom who isn’t restricted by this NHS ethical dilemma’. Once under the care of a surgeon an NHS patient may well have missed the chance to opt for a better lens.
In reality it may be that a patient with private healthcare can use that to fund the procedure and pay additionally for the optical product. Optegra in Guildford sees private and NHS patients but, says Passmore, the NHS patients will get a monofocal IOL: ‘The structures in place do make it difficult because there’s not one size that fits all. We have got patients coming through saying that if they had known they would have made a different choice. The optometrist plays a crucial role in that. It’s a professional responsibility for them to talk to patients about that.’
For the moment, given that agreements and patient pathways are different in different areas, Optegra will continue to work with optometrists to furnish them with information to pass on to their patients.
Passmore is working on a range of agreements that will see the patient returned to the referring optometrist post-surgery for follow up. He says Optegra works closely with Boots Opticians and is talking to the Local Optical Committee Support Unit to develop more referral schemes. It also bids for ophthalmology tenders from the NHS and most recently won the Eastern Cheshire ophthalmology contract. What it wants to build with community optometrists is a collaborative approach to care pre and post surgery regardless of the funding model. ‘The long term care of our patients is critical and we want to make sure that happens to the highest standard.’
Another area in which Passmore says Optegra has an edge is its specialism. It deals only with eyes and has consultants who are vision specialists. ‘People might come in for RLE and find they have other eye problems that need addressing,’ he says. Optegra offers a wide range of treatments which could help.
When it comes to refractive options Optegra walks the line between the forefront of technology and the tried and tested. It is an area Passmore sees experiencing ‘exponential growth’ and younger patients coming through. ‘The improvements in lenses is incredible,’ and makes the point that Optegra was a pioneer of lens exchange.
The person given the job of keeping Optegra in that position is Dr Clare O’Donnell (pictured), head of Optegra eye sciences. OES is a non-profit unit that monitors the products and procedures used and carried out by Optegra to provide evidence for efficacy and determine product choice. She says the levels of data on patient outcomes, the test algorithms it has developed and the data generated by its key performance indicators have made OES the go-to place for suppliers looking to have their IOLs evaluated.
She says by working with international groups and gathering more patient data she will be able to provide the evidence that will answer questions, from colleagues such as community optometrists, on RLE and advanced technology multifocal IOLs. All of this will build to dispel many of the myths, she says exist, around the performance of multifocal and toric IOLs. ‘When optoms come in they still ask: “Do they really work?” Consultants often comment that success rates with multifocal IOLs are higher than with multifocal contact lenses.’
The boundary between primary care optometry and secondary care ophthalmology is being blurred, she concludes. ‘We firmly believe that patients need to have the information to make the best decisions for them. From a medicolegal point of view it’s up to us to provide the right information.’
For some people a standard IOL design might be acceptable but for others they would like something better and it is up to optometrist to help provide the information that allows them to make the choice. ‘Informed consent means just that,’ says O’Donnell.