Holding aloft the flag of clinical services for optometry and hoping everyone else would follow was a nice idea but it is not going to happen, says Doug Perkins, chairman and co-founder of Specsavers. His reference was to the plea he made at Optrafair. In the absence of a cohesive, pan-profession push for access to ophthalmology he says Specsavers has decided to build an evidence base to convince ophthalmology of optometry’s worth through clinical outcome reporting.
‘Tracking outcomes of clinical interaction has been done for years in other areas but in optometry it’s a pretty new thing,’ says Giles Edmonds, clinical services director of Specsavers. That is exactly what Specsavers has built through its clinical outcomes reporting that is now live in 600 stores. The idea is to generate data on things like referral reporting to help build better relationships with ophthalmologists.
Referrals are an issue when optometry approaches ophthalmology. ‘In most cases, its the first thing they throw back at us,’ says Edmonds. The system it has devised allows referrals to be tracked from stores and individual clinicians so the practice lead can have conversations with individuals about the quality of their referrals. ‘What I can say is the variability of referral rates is quite stark across the organisation and I don’t think that’s any different to any other organisation. The great thing is we can now start to measure it.’ He says that Specsavers is the only organisation to do this and it will enable it to benchmark referrals rates against the norm.
‘It’s definitely the way forward for us because we need that platform for measurement and collecting data that will have great use for the practices,’ says Perkins, but it will take time.
Edmonds says one of the key learnings has been the tracking that ophthalmology does on the rates for all of the procedures performed and their outcome. These are then discussed at annual reviews with a mentor. He wants to take that and build it into optometry because it will be good for governance and retention. It will also foment good clinical governance in practice with lots of communication between lead optometrists, partners and other optometrists in practice. This all fits in with the requirements in the GOC’s business standards for peer to peer review. ‘We are ahead of the game in terms of what that looks like,’ he adds.
With the systems all in place and live reports coming through, Edmonds is under no illusion that full implementation will not be so easy. ‘Embedding it into the organisation is going to take quite a time and changing performance as well,’ he says. Specsavers already has research showing how much more effective more experienced optometrists are with referrals than newly qualified ones, so that learning has to be shared. ‘This will show our partners where mentorship is required,’ says Perkins, ‘and join up the clinical teams so they can rely on what is happening in the examination room.’
The system will generate a report once a month giving the opportunity for review around benchmarking both nationally and locally. Referrals, recalls and interactions are recorded each day and logged. The current thinking is that the referral rate should be 6 or 7% but the variability will be up to 20% for newly qualifieds that needs mentorship and coaching. They cannot be experienced from day one. ‘Having a buddy system once they have qualified is a really important part of this as well.’
Doug Perkins and Giles Edmonds
He says the GOC has been very positive. ‘Hopefully we can work with ophthalmology to genuinely reduce false positives.’ It is a mammoth task but one Edmonds thinks Specsavers is well placed to put into action. ‘If you haven’t got a patient management system set up in the right way it’s very difficult to do manually,’ he says. Much of the methodology required in the business standards, due to come out in October, and Edmonds says Specsavers is fortunate in having the structure to set up reporting. It has also learned from Newmedica, its ophthalmology partner, and has prior learning from Australia as to how the two disciplines can interact. To implement the process across northern Europe Specsavers will be bringing over expertise from Australia to roll out the idea. ‘It will be great to get professional services on the same track everywhere so this can be the norm for optometry working,’ says Perkins.
But it will require action from individual clinicians. The system provides the lead optometrist with a portal to all metrics around clinical interactions from which reports on performance by practice and individual clinicians can be viewed. ‘The idea is you can print off an individual clinician’s report, give it to them and have a one to one conversation.’ The data will include things like recall intervals, which are important and vary, but will help with PPV (Public Patient Voice) visits where adherence to the guidance is checked. He says recording justification for things such as early recalls is vital as eGOS is implemented and the NHS will have huge amounts of data at its fingertips. ‘We are making sure we are in the right place.’
The reports generated by the system not only include referral rates but where referrals have been made and what they were for. These use the descriptions used by ophthalmology. All of this can be analysed at a clinician level and advice given.
The ultimate goal is to manage more in practice and to have the confidence, supported by field testing and OCT, not to refer but to monitor the patient until more clinical signs are evident. This will prevent patients being put on waiting lists for up to nine months. ‘They [ophthalmologists] are not interested in the most minor blemish, you have got to get this clinical expertise in the high street, unless [you do that] you are just a pain in the arse for them really.’
Edmonds says optometrists and ophthalmologists have to talk. In his practices, he says the local ophthalmologists say: ‘“Unless I am going to treat it don’t send it to me.” They trust us to manage it and our referral rates have dropped right off. You can’t refer something just because you haven’t seen it before.’
The scheme is currently live in 600 stores and Specsavers is looking to add additional resources to support clinicians. This will take the form of divisional coaches who will work with store partners but activity has got to come from the shop floor. Unless the reports are being generated and acted on its not going to work, says Edmonds. The system can see centrally a report for each store and change in referral rates. ‘If there is no change in referral rates in a particular store you can bet your bottom dollar they are not having those conversations. It also works the other way. If a store has fewer referrals are they under-referring or managing patients in a better way? By monitoring reports and using suitable training rates should improve. If there hasn’t been a change you can see in subsequent reports so it’s a really nice loop. We are looking forward to seeing the changes,’ he says.
And if Specsavers gets it right, the changes could be significant. It currently accounts for half of all referrals into the NHS, 5% on 10 million eye tests. ‘It’s a big deal for us to make sure we are reducing our false positives and it would be great if the rest of the industry follows.’
Perkins gives an indication of how things could be by looking at Australia where patients are turned around within four weeks of referral, here is it between six and nine months. The different funding model means Australian ophthalmologists are paid for all referrals, whether genuine or not so they make sure they have a good relationship with optometry to keep referrals coming. They are also better at feeding back outcomes. ‘What would be brilliant is that you refer a patient and you get positive confirmation that that patient was referred correctly,’ says Perkins. Through the privatised system, they are starting to get that because the ophthalmologists are keener to get referrals. Getting NHS ophthalmologists to give us feedback is not so easy. The culture means quite often ophthalmologists do not get feedback from colleagues in the same hospital.
So how will they get that feedback? ‘We won’t get it 100% across the country,’ says Perkins. ‘We have got to live in the real world we will establish best practise with those people who have direct referral and are motivated to keep a relationship with optometry and are willing to have that two way link with us.’ From that he says a lot of the data can be extrapolated. ‘It’s not ideal but it will allow us to establish that our referrals are consistent and we are adding value in enhanced optical services,’ he adds. Optometry has to get involved in clinical eye service to enable the NHS to cope, says Perkins. ‘At the end of the day they are not meeting demand and they are not going to be able to run away from that.’