Guidance for providers of cataract services was published by The Royal College of Ophthalmologists in March and included details of how patients could be better managed in the community by optometrists.
A Cataract Workforce Guidance Development Group, led by consultant ophthalmologist Jonathan Bhargava, was set up to support local eye health systems in meeting an increasing demand for cataract surgery in a joined-up way.
‘We’ve done this deep dive on the whole pathway and looked with a fresh pair of eyes at how it can be improved,’ Bhargava told Optician.
Guidance was commissioned by the College because of the wide variation of how cataract services were provided throughout the UK.
‘It was about how we could make cataract surgery a more streamlined experience for patients by optimising the pathway and utilising the vital resource of community optometrists,’ Bhargava explained.
He said that it was the Getting It Right First Time (GIRFT) report for ophthalmology, which was published in December 2019, that influenced the formation of the Cataract Workforce Guidance Development Group.
GIRFT made recommendations for all NHS trusts to make better use of theatre time for routine cataract surgery and improve patient care.
Consultant ophthalmologist Jonathan Bhargava led the Cataract Workforce Guidance Development Group
Bhargava said: ‘One of the recommendations made in GIRFT was instigating post-operative care in the community by optometrists. The advances of cataract surgery techniques lend themselves to this ideal of shared care; that a patient is coming to the hospital pretty much for their assessments and operation and then visiting their optometrist following that.’
He added that at Countess of Chester Hospital, where he worked as a consultant, a post-operative clinic was led by a nursing team, but its time was needed elsewhere. Local optometrists were commissioned for a post-operative service, which started properly after lockdown restrictions eased and was ‘working beautifully’, Bhargava said. ‘It’s great that the community optometrists are so keen to be involved with this. Now, all the hospital staff who were doing those clinics have been reallocated to do other important work where the capacity pressures are.’
GIRFT also highlighted disparities in the number of surgeries performed in different regions. Bhargava noted that Sunderland Eye Infirmary was completing more than 10 surgeries while the lowest in other regions was four in a four-hour session. GIRFT recommended a target of eight patients on an operating list.
Service reset
The Cataract Workforce Guidance Development Group’s report was developed with insight from regions across the UK. ‘All the pathways were developed between the group as a whole and taking the best bits of everybody’s current practice,’ Bhargava said.
He added that if GIRFT was an assessment and setting of targets, then the group’s report was a how-to guide. He explained: ‘If someone is interested in improving their pathways and streamlining, this document will explain in detail how that can be brought about.’
The College’s guidance highlighted what the GIRFT report recommended and explained how it can be achieved in a local unit or region. Bhargava said: ‘It’s for optometrists as well because they’re closely involved. It is a how-to guide. How can we achieve increasing the average from seven cases to eight cases on an operating list?’
One important role for optometrists, Bhargava said, was the initial referral and determining if the patient wanted surgery. ‘Sometimes patients get sent into hospital with cataracts but they don’t want surgery. This is particularly pertinent at the moment because of the pandemic. People don’t want to come into the hospital at the best of times,’ he added.
During the first Covid-19 lockdown, all elective surgeries stopped and a delay to restarting cataract surgery was created. In response, the College’s Covid-19 team developed guidance to restore services and the Cataract Workforce Development Group used these to create a set of Covid-safe pathways ready for when surgery could begin again with the Cataract Workforce Guidance.
‘The pandemic has been terrible but it has allowed us to perform a reset of our services and think about how we can improve,’ Bhargava said.
Prior to the pandemic, all patients in Chester were asked to attend the hospital on the day of the operation and seen throughout the morning. A staggered admission system has been instigated and patients were given eye drops to apply at home, so they arrived dilated.
In Chester, the team has provided an extra 900 appointments over the past four weeks in order to address the backlog by working at weekends with junior doctors and nursing staff.
Continuity of care
Bhargava said if a hospital service was having problems with referrals then the new guidance offered an opportunity to instigate the optometry led referral refinements scheme. ‘That can be a big change for the optometrists. It would be working hand in hand with the hospital service and being more involved. For patients, the post-operative care they’ll get will be with the optometrist who referred them, which is great continuity for them,’ he explained.
Closer collaboration between primary care optometrists and hospital services were very important, Bhargava said, and the use of an email referral system in Chester has made the referral process smoother. Optometrists send an electronic report with information about post-operative refraction and if they could be discharged or whether the patient would like their second eye operated on.
Service planning
One tool included in the guidance was a calculator to support workforce planning in meeting the increasing demand. The population of the area where services were delivered could be input into the calculator and it would tell you how many over-50s there were.
Additionally, the hospital team would receive a prediction of how many cataract surgeries there would be over the next year based on research and figures from the Office for National Statistics. The number of nurses at the hospital could be added to see what could be achieved with existing staff and how many community optometry appointments were needed.
‘Using the tool, we’ll be able to see in 10 years’ time that we might need an extra eye theatre because we’ll need to provide so many extra operations; or not, if we streamline what we’re doing. That’s also planning for the CCGs [Clinical Commissioning Groups] because they’re the ones who’d be commissioning services of community optometrists,’ Bhargava said.
‘This is a way to show how many optometric practices there are in an area. It gives them the ability to see what could happen. If they go down one route and the hospital does want to do the shared care in the community with the postoperative care, then they’d know they would need to provide however many extra appointments. Up until this point, that hasn’t been able to be forecast.’
Bhargava explained that the calculator was for planning services, whether that be at hospital, CCG or LOC level, to see how many appointment slots were needed and therefore how many optometrists were needed in an area.
‘One of the best analogies I can use is that of a Formula One pit stop. A pit stop from the 1950s took ages when compared to one from a couple of years ago where they changed all four tires in two seconds.
‘Everybody in the team is really important and if you take one person away or put somebody else in who is not familiar with that system, then it’s not going to work as well. It’s about having the right staff in the right place at the right time and that includes optometrists. The skills are there. It’s just unifying everything. That’s hopefully what this guidance will allow us to do,’ Bhargava concluded.
Useful links
GIRFT report:
RCOphth guidance: