Steps to better care

In 2002 the Department of Health established the National Eye Care Steering Group.1 The group was given the remit to look at current delivery of services for long-term eye conditions and to investigate and research ways in which this could be improved to provide more efficient patient-focused and integrated services across primary, secondary and social care.
The value of the role of the voluntary sector was also acknowledged and emphasis placed on incorporating these providers into the new pathways. The new approach would ensure that best use was made of available resources and skills, so that patients would experience minimum waiting times and services would be more accessible, as well as providing an element choice about where and how the services would be provided.
The areas considered by the steering group in the design of the new pathways related to where and how the service could be provided, who could provide the service and ways of reducing the number of patient steps in the care pathway. To date, the work has focused on care pathways for the four most common eye conditions - cataract, glaucoma, age-related macular degeneration and low vision.
Diagramatic versions of the pathways are shown on pages 24 and 25 and full details of the pathways can be found in the National eye Care Services Steering Group First Report.2 It can be seen from the diagrams that no pathway involves more than four patient steps and all the pathways work to eliminate duplication, whether this relates to patient appointments and investigative tests or administration. The pathways also show a strong interface between primary and secondary and close working with social care and the voluntary sector as and where appropriate.
Once the design of the pathways had been agreed by the eye care services steering group, primary care trusts (PCTs) were invited to submit proposals to pilot one or more of the pathways. However, it was recognised by the steering group that for implementation of the cataract pathway, waiting lists for cataract operations would need to be three months or less. For the other pathways, selection for acceptance to pilot the new pathways was based on how well the proposal demonstrated the principles of the pathways, in particular how the pathway would cross the primary/secondary care divide and how patients would be involved in the pilot. The patient involvement at all stages of design, implementation and review is seen as being integral to the development of services that truly reflect the needs of those using the services. From the PCT bids, eight pilot sites were selected (Table 1).
These pilot sites were notified of their successful bids last May at the launch of the Eyecare Steering Report. Since then the sites have been involved in finalising project plans, protocols and patient pathways, as well as appointing staff, purchasing equipment and setting up training.
In addition to this, for some of the pilots, there have been tasks such as dealing with building renovation and even acquiring premises where the pilot could be based. The experiences gained by the sites have been logged and will form an invaluable asset for other PCTs when they are looking at the implementation of the pathways following the conclusion of the pilot period.
All of the pilot sites are now seeing patients and it is as this stage develops that there will be extensive evaluation to develop a good evidence base for further activity. The evaluation will look not only at the effects of the new services on waiting times and ease of access, but will also look at the experiences of both the patients and the staff. All sites will be undertaking various review processes to look at potential implementation changes to further improve service delivery and ensure that the service is accessible to all sectors of society. It can be expected that information will be available as from this spring, including presentations and a stand at the international Vision 2005 conference, being hosted by RNIB in London from April 4-7. Information will also be available on the Department of Health website.
The eight pilot sites will be joined later by further associate sites, which could be regarded as the first stage of rolling out the eye care pathways on a wider basis. The pilot stage of the eye care pathway programme will finish in the summer of next year and after completion of the evaluation, the pathways will be recommended to all PCTs as the basis of future commissioning for eye care services. The PCTs hosting the pilot have already agreed to take the services from project status to sustained service.
This programme and the work of the Eye Care Services Steering group will influence the delivery of eye care in the UK for many years to come. It will enhance the role of the optometrist as a full member of the primary care eye team, allowing the development of skills so that many tasks undertaken currently in secondary care will become the function of the community optometrist.
These tasks will include carrying out functions such as diagnosis and monitoring of eye diseases such as glaucoma and AMD in the primary care setting by appropriately trained optometrists. Not only will this provide optometrists with the opportunity to develop and use their skills, it will also allow patients to access these services in a convenient location and at times that are convenient to them.
It will also offer increased satisfaction for the practitioner because they will become part of a bigger team that works with the patient as a whole person and not just a pair of eyes to meet multiple needs. This is particularly important for patients with low vision where the integration of health and social care services to form one team will really ensure that the needs of the people using the services are fully met and so help them to maintain an independent lifestyle with dignity and choice.
It is now up to the professionals to engage in these opportunities as they develop and take the work of the eye care services to a new level and standard. It is time to forget old barriers and ideas and to develop as part of truly professional multi-disciplinary team using systems that have developed from sound evidence-based methodology.

References
1 Winterton, Rosie. The future of eye care services. optician, 2005; 5985: vol 229, page 25.
2 Department of Health/Optical Policy, First Report of the National Eye Care Services Group, Gateway Ref: 3170 Department of Health.
Anita Lightstone is head of low vision and eye health at the RNIB and programme adviser to the NHS Eyecare Services Team

BOXTEXT: Table 1. Pilot sites
Glaucoma
East Devon PCT
North Birmingham PCT
North and South Peterborough PCT
Waltham Forest PCT

Low Vision
Barking and Dagenham PCT and Havering PCT
Gateshead PCT
Sutton and Merton PCT with Wandsworth PCT
Waltham Forest PCT

AMD
Brighton and Hove PCT
Waltham Forest PCT