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There are a number of services that it would make sense for optometrists to provide instead of secondary care, from cataract and glaucoma referral refinement, stable glaucoma monitoring, to PEARS-style triage schemes.
What makes PBC really important for optometrists is its combination with payment by results (PBR) and the introduction of national tariffs. National tariffs introduce rates payable for certain procedures and appointments. For the first time, therefore, it becomes possible to make direct cost comparisons with the hospital. Under this system a new 'adult first attendance' in an ophthalmology outpatient clinic will attract a payment of just £106 (2008/9) and a 'child first attendance' a little more. Follow-up appointments will attract payments of £48. These tariff are also subject to a market forces factor (MFF) which varies throughout the country (full details of tariffs and MFFs can be accessed from the LOC briefing pages of www.primaryhealthnet.com).
If optometrists can offer services mirroring those provided in hospital at less than the tariff price and provide a service that reduces initial appointment, commissioners are likely to be interested. Simply discussing risks of surgery with potential cataract patients can see a dramatic fall in hospital appointments and glaucoma referral refinement has been shown in several cases to reduce false-positive referrals from primary care by up to 30 per cent. With GPs and PCTs keeping 70 per cent and 30 per cent respectively of all cost savings made, you can immediately see why both groups are interested in reducing unnecessary hospital appointments. Where independent treatment centres (ITCs) are involved in providing treatment to patients (most commonly cataract surgery in the case of ophthalmology), potential cost savings can be even more dramatic. Most PCTs will have agreements in place with ITCs, whereby a certain number of slots are paid for whether or not they are used. In many cases, take up is not what was expected, with referrals still being made to the traditional secondary care provider and PCTs are therefore effectively paying twice for the same service. If referral patterns can be changed through PBC schemes then the savings made can be even greater.
Not all about money
Of course, it's not all about money. One key target in the NHS is the 18-week wait. The expected target for 2008 is that 90 per cent of admitted patients and 95 per cent of non-admitted patients will have been seen and treated within 18 weeks of referral (further details from www.primaryhealthnet.com). There is pressure on secondary care, PCTs and GPs to meet this target and in some areas of the country it is proving very difficult. As we have seen, optometrists can be instrumental in reducing referrals and carrying out follow-up appointments that would have traditionally been carried out in secondary care. This can free up vital resources within the ophthalmology department, allowing the 18-week target to be met and actually gaining you the support of the ophthalmologists rather than resistance. This is such an important target to be met that even if services being provided by optometrists are cost-neutral, they will in many cases be commissioned.
Of course, the one person that hasn't been mentioned yet is the patient. While it is probably essential that any commissioned service ticks the cost saving or 18-week wait box, you shouldn't forget all the very real benefits to the patient. Services in most cases can be provided more quickly, more conveniently, closer to home or work and with a known and trusted practitioner.
To conclude, it is clear that there are a lot of opportunities for optometry in the near future. Your LOC should be talking to commissioning groups and PCTs to promote the many services that can be offered and if they're not, maybe you should be seeking election at the next AGM. ?
Charles Greenwood is director of JCL Consulting
