In an article allied to our ongoing series on the eye care pathways, Dr Kamlesh Chauhan and Dr Rob Hogan describe a view from the perspective of a major high street multiple
In December 2002, the Government set up a National Eye Care Services Steering Group to develop proposals to improve eye care. The overarching aim was to develop an integrated, patient-centred service with improved access, choice, waiting times and quality for all sectors of the community.
It might have confused some within the profession that diabetes was not included within the remit of the Steering Group. Its exclusion from this programme was as a result of its prior inclusion in a separate and already set-up programme - the Diabetes National Screening Framework.
This is now being implemented in a variety of manifestations within the majority of the UK. A fifth pathway was also proposed, covering aspects of treatment of anterior eye disease. The various stakeholders within this area of eye care are now working to develop an agreed and effective framework to allow optometry to be fully involved in this. This will, however, require training, formal accreditation and legislation, while acknowledging and remunerating the optometrist's knowledge, skill and equipment to potentially play a stronger role in reducing the burden on secondary care and providing accessible primary care within the community and high street.
PRIMARY EYE CARE
Within each of the existing four pathways there are proposals to make effective use of primary eye care health providers, ie optometrists, dispensing opticians and ophthalmic medical practitioners. The idea is that the increased funding to secondary healthcare can only be used effectively if referral from primary care providers is accurate and necessary. The added advantage will be that patients will have timely and convenient local access to primary eye care within the community, until appropriate and informed referral into secondary care becomes essential.
In December 2003, the steering group presented its first report and developed four principles to achieve these aims:
At this stage, bids were welcomed for funded innovative pilots for the four pathways in order to trial the proposals. Eight schemes were successful in the bidding. Optometrists and primary care trusts alike await the appraisal and analysis of these pilot schemes with interest as they will enable them to more effectively plan and implement their own pathways.
It is to be hoped, however, that the variation and disparity within the current diabetic schemes (with respect to criteria for inclusion and referral, equipment and funding, and so on) are not replicated in the remaining pathways.
It is expected that the resultant schemes adhere to the principles outlined in the agreed document Transparency in co-management that has been collaboratively produced by the AOP and FODO for the benefit of PCTs and practitioners alike. Many of these issues would have been more easily and equitably navigated if our professional bodies had been able to negotiate centrally.
The four design principles, outlined above, permit the patient to avoid the overly-subscribed secondary care system until absolutely necessary and to be taken care of within primary eye care in community high-street practices. In order for these patient-focused changes to happen with the full and effective involvement of primary care optometry, several changes are however required:
As with many other opticians, D&A remains vigilant of these changes and the potential opportunities they offer. For example, in many ways our decision to replace our fleet of existing field screeners with Zeiss Humphrey visual field analysers was made much easier knowing that it is the 'gold standard' and is widely used in hospital eye departments. Within the principles of the shared care pathways in general and the glaucoma pathway specifically, it will be important to ensure accuracy in diagnosis and referral and a reduction in false positives.
Accreditation of knowledge, skills and competency, be it at local or national level, will require continuing education and training above the entry level competencies mandated in the GOC's compulsory CET scheme. To underpin this, D&A is providing a programme of CET well in excess of the requirements of the GOC's scheme for the purposes of maintenance of registration.
While it accepted that the above changes should improve patient care and service, there is no doubt that there is a strong financial incentive for the DoH for these pathways to succeed, stripping out secondary care costs while shifting the burden on to the primary care provider. While many of us wish to embrace the opportunities these pathways present for professional advancement, role enrichment and patient service, optometry has to ensure, however, that it is economically and fairly remunerated for its key involvement. For the pathways to be a success, the profession will require payment substantially above the new NHS sight test fee (of £18.39), which clearly does not value at economic rates the professional time and expertise involved.