Whoever knew so much could change so quickly? At Newmedica we emerged from lockdown piecemeal, but in some ways stronger, safer and more efficient. All our services are open at the time of writing, some more than others. A few use operating theatres that are seconded to the NHS, but otherwise we are performing cataract and other eye surgery on routine (but often significantly visually handicapped) patients for the first time since February.
One of our locations never stopped working at all. Our Teesside clinic in Middlesbrough worked with the local NHS Trust to provide macular degeneration services during the outbreak, as this was defined as a critical service. Trust staff and our staff worked together to maintain services for patients who needed care, and we had a great opportunity to build on existing good relationships with the acute provider. Hats off to all those who worked with patients during that most uncertain time early in the epidemic.
The changes patients are seeing today will be familiar to readers: PPE, isolation, distancing, confusion over Covid-19 testing (we are not, if you are interested). The patient journey is quite a lonely one; most never meet another patient. Which means it is slower, but perhaps not as much as you would think – 30% slower perhaps. We try very hard to put patients through this journey as few times as possible, and it has been refreshing to think hard about not wasting time.
Provided we get a good steer on diagnosis on the referral (help us out here, please) we can start with a video or phone call, decide on a provisional plan, and only bring patients in for a face to face appointment when we are to do a procedure. With the follow-up appointment also on the phone, it means cataract surgery can be performed on most patients in one visit to one of our clinics in an hour – see, diagnose and treat. This is a significant change for us and is significantly better for the patients. It is safer, less time in clinic, less travelling and more convenient, so it is likely to be one area we will not go back on when the crisis is over.
A typical patient journey might look like this for a cataract operation:
- Referral by optician or GP
- Referral clinically triaged by ophthalmologist
- Admin phone call
- Appointment confirmation and patient information booklet sent by email
- Remote consultation with refractive and consent discussion
- Fourteen-day isolation before attending a face to face appointment
- Covid-19 screening call 48 to 72 hours before arrival
- Arrive by car and wait for a member of the team to invite patient to enter the hospital – it is one patient in and one patient out
- Patients provided with a face mask and hand sanitiser
- Staff wearing appropriate PPE
- Biometry, scans, examination and consent
- Surgery immediately if agreed
- Post-operative discussion
- Return home
- Post-operative follow-up call
We are discovering just how much can be achieved remotely in a specialty that historically has been considered unsuitable for anything other than face to face slit lamp examination. Oculoplastic surgery is ideal – we can diagnose and plan treatment with a video call or a photograph, and the patient has a chance to meet the surgeon who will perform the surgery before the day. It is amazing how elderly patients have become confident in the use of technology, when for months it has been the only way of keeping in touch with family and friends.
Glaucoma requires diagnostic tests, so we are setting up safe testing centres with remote reviewing – again we will not be going back to where we were in glaucoma diagnosis and monitoring, and the service can be led by a glaucoma specialist ensuring consistent standards of care.
Diagnosis of complex eye conditions is less easy remotely and here we have to get the patient to the right specialist with the fewest visits possible. The more information with the referral the better we can do this. Second opinions from experts via live slit lamp streaming have been shown to work and this has massive potential both in the primary and secondary care setting if we work together.
New technology certainly helps. Anterior segment OCT gives a good steer on narrow angles and avoids gonioscopy. Binocular OCT holds much promise for a near full eye examination. We are becoming more confident with alternative IOP methods and the Goldmann is reserved for those who really need it.
Patients have loved the attention to safety and have been putting up with the delays. As confidence grows and the virus recedes, the more extreme precautions can slowly be relaxed. But when the tide goes out the beach will not look quite the same again. The transition in the UK of routine ophthalmic care out of acute hospitals and into discrete specialised community-based provision is a movement which has gained huge momentum by this national crisis, and it will be permanent.
Tim Manners, consultant ophthalmologist and Newmedica Ophthalmology Joint Venture Partner, Lincolnshire.