Transcript Chronic Eye Disease Management in Community settings:

NatPaCT works with Primary & Care Trusts
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and leaders of radical change
to improve health & services for patients.
Chronic Eye Disease
Management in Community
Settings:
First Report of the Eye Care
Services Steering Group
Bob Ricketts
Head of Access Policy
Development & Capacity Planning
Department of Health
Blindness: Vision 2020 - The Global
Initiative for the Elimination of Avoidable
Blindness
•disease prevention and control
•training of personnel
•strengthening of the existing eye care
infrastructure
•use of appropriate and affordable
technology
•mobilisation of resources
NHS PLAN
Core Principles 3,4,8
• The NHS will shape its services around
the needs and preferences of individual
patients, their families and their carers
• The NHS will respond to different needs of
different populations
• The NHS will work together with others to
ensure a seamless service for patients
“Fair for all
and personal
to you”
John Reid
16 July 2003
Eye Care Services Steering
Group
• Set up by Ministers in December
2002
• Worked on GMS, dentistry and
pharmacy and ophthalmics now
moving forward
• Growing need for eyecare services
and major quality of life issues
Population Milions
Demographics
12
10
8
6
4
2
0
10.5
7.9
5.5
4.1
65 to 74
3.8
Year 2002
Year 2020
5.0
Over 75s Over 65s
Population Increase
65 - 74
34%
Over 75s
33%
Over 65s
33%
Source ONS
Source ONS
• Half of over 65s have impaired
vision in one or both eyes
• Increase in elderly
Four Pathways
• Cataract
• Glaucoma
• Age Related Macular Degeneration
(ARMD)
• Low Vision Services
• Diabetic retinopathy being tackled
separately as part of Diabetes NSF
Design Principles
• Make best use of available resources
• Have fewer steps for the user
• Make more effective use of professional
resource
• Show a high standard of clinical care with
good outcomes
• Improve access and deliver greater patient
choice
• Evidence based
Conclusions
• Primary care ophthalmic services need to
be developed to meet demographic
demand
• Partnerships with primary & secondary
care, patients and carers essential
• Integrated IT needed but not prerequisite
• Voluntary agency and social services
involvement important
Care Pathways Designed to Achieve:
• Integrated eye care services
• Better use of skills in primary care
• Increased amount of care for all in
accessible primary care settings
• Increased role for professional groups in
primary care
Recommendations
• Cataract pathway to be implemented when
waiting times reduced to 3 months
• £73million additional funding to achieve 3 month
cataract waits by December 2004
• Glaucoma pathway to be piloted initially
• ARMD and Low Vision to be taken forward
within existing funds
• £4million for innovative projects and pilots
• GOS Regulations to be amended to allow direct
referral by optometrists
Why are we here?
• Share our report with you
• Consider, if you agree with us,
how we take it forward
together
Elizabeth Frost
Director
Association of Optometrists
&
Chair, Cataract Working Group
Background
• Mainly elderly population
• Many misconceptions about cataract
surgery
• Changes in HES
• Action on Cataracts
Current Cataract Pathway
1. Patient reports sight problem to GP
2. Patient goes to optometrist/OMP for sight test and
optometrist/OMP refers patient to GP
3. Patient goes to GP, referred to HES
4. Patient seen at HES, cataract confirmed, decision to
operate, and put on waiting list
5. Patient attends HES for pre-op assessment
6. Patient attends HES for day case surgery
7. Patient attends HES for 24 hr check
8. Patient attends HES for 6 week check, 2nd eye
discussed
9. Patient attends optometrist/OMP for sight test and new
specs.
Proposed Cataract Pathway
1. Patient attends optometrist/OMP for sight test, cataract diagnosed
and discussed, general risks & benefits of surgery explained,
current medication listed, patient information given, and
appointment made for HES, with choice of provider (copy of referral
to GP for info)
2. Patient attends HES to see ophthalmologist and for pre-op
assessment
3. Patient attends HES for day case surgery
4. Patient attends HES/optometrist/OMP for 24/48 hr check OR is
phoned by cataract nurse to check progress (agreed locally)
5. Patient attends optometrist/OMP for final check and sight test, 2nd
eye discussed.
Proposed Cataract Pathway
Start
Finish
1. Patient attends optometrist
•Sight test, cataract diagnosed and discussed
•General risks and benefits of surgery discussed
•Patient wishes to proceed, information given etc
•Patient offered choice of hospital and appointment agreed
2. Patient attends HES
•Outpatient appointment with
ophthalmologist*
•pre-assessment (with nurse?)
•Date for surgery arranged/agreed
(* details of medication etc
received from optometrist, GP or
patient as per local protocols )
4. Patient attends HES
or Optometrist
•Final check
•Sight test
•Discharged or
nd
2 eye discussed and
appointment arranged
3. Patient attends HES
•Day case surgery undertaken
Who should be referred?
• Not a ‘fast track’ service
• Suitable for those who –
– have a cataract that is interfering with their
daily living
– have been given basic information about
cataract surgery, and risks / benefits
– want to have surgery
Evidence of Success
•
•
•
•
•
•
•
•
Several services developed and audited
90%+ referrals proceeding to surgery
cf 80% for traditional referrals
Reduced time to surgery from 12 to 3 months
Surgical outcomes meet RCO guidelines
Reduced DNA rates
Greater nurse involvement
High patient satisfaction
Constraints to Success
• Not funded centrally through GOS budget
• To be funded by existing PCT budgets
• Investment needed in equipment and
staffing
• Needs mutual inter-professional trust and
teamwork
• Lack of IT booking links will hamper
Key Recommendations for local
action
•
•
•
•
Reduce number of steps in pathway
Eliminate duplication
Improve IT links – optometrist/OMP/HES
Develop protocols for discharge from HES
to optometrist/OMP with audit feedback
• Agree funding
Stephen Vernon
Royal College of
Ophthalmologists &
Chair, Glaucoma Working Group
Chronic Glaucoma gives tunnel vision
10 years
Testing for glaucoma
UK population by age - 2001
UK population by age 2001
5
4.5
4
no in millions
3.5
3
2.5
2
1.5
1
0.5
0
0-4
5.0-9.0
10.014.0
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
Age range
55-59
Age range
60-64
65-69
70-74
75=79
80-84
85-89
90+
BMES PREVALENCE OF POAG
12
Percentage
10
Observed
Expected
8
6
4
2
0
0
<60
60-692
70-79
80+
4
<60 60-69
70-79 >80
Age group
Age Group
Estimated numbers of glaucomas in UK by age (1000s)
Nos of glaucoma in UK by age
70
60
No in thousands
50
40
30
20
10
0
35-39
40-44
45-49
50-54
55-59
60-64
65-69
Age
Age
70-74
75=79
80-84
85-89
90+
Current Glaucoma Pathway
(Hospital Based Care)
1. Single screening opportunity by
community optometrists with no
standardised protocols
2. Diagnosis and continued care for life
of all glaucoma (and many
suspects) within Hospital Eye
Service by ophthalmologists
Proposed Pathway
(Community Based Care)
1. Community optometrists work to
nationally agreed screening protocols
which permit refinement of tests prior to
referral
2. Glaucoma suspects and stable glaucoma
patients managed in the community by
COs and OMPs with interaction of
community and HES teams where
appropriate
The 5 Care Pathways
Care Pathway 1
Ocular Hypertension
Care Pathway 2
Glaucoma without other eye disease
Care Pathway 3
Glaucoma suspect on discs and/or fields
Care Pathway 4
Glaucoma in presence of other significant eye disease
Care Pathway 5
Refinement of community optometric referrals
Proposed Glaucoma Pathway
Start
1. Patient attends community optometrist (CO)
•Sight test, IOP over 21 (applanation tonometry) and/or
visual field defect and/or excavated discs
•Patient/optometrist makes appointment with optometrist
with special interest in glaucoma (OSI) or OMP
2. Patient attends OSI or OMP
•Full history and assessment carried out according
to protocol
•Decision taken as to whether patient has ocular
hypertension (OSI/OMP reviews) or can be
discharged (return to CO) or has glaucoma (treat
or refer to HES)
•Patient advised, given information etc and further
appropriate appointments made if needed
4. OSI/OMP
manages patient in
community setting
•Regular reviews set in
place
•OSI/OMP relay data to
hospital if significant
progression for HES
review if needed
3. OSI/OMP relays data to HES
•HES reviews data, advises OSI/OMP
regarding management and sets up
review at HES if needed
Evidence Base
• Only 33% of suspect glaucoma referrals
found to have glaucoma by HES
• Optometrists with additional training can
assist in glaucoma management freeing
up ophthalmologist and hospital time
• Refinement of referrals for suspect
glaucoma by specially trained optometrists
reduces HES referrals
Constraints to Achievement
•
•
•
•
•
•
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Funding issues - increased revenue costs
Training requirements
Legal issues for prescribing rights
Information Technology issues
Communication
Record keeping
Audit
Key Recommendations for Local
Action
• Community optometrists conform to College
guidelines for referral of glaucoma suspects
• HES services utilise optometrists to assist in
glaucoma care within the HES
• Community refinement of optometric referrals
established utilising OMPs and optometrists with
a special interest in glaucoma
• Community care of “straightforward” glaucoma
cases by OMPs and optometrists with a special
interest in glaucoma
Frank Munro
President
College of Optometrists
&
Chair, ARMD Working Group
OBJECTIVES
• Map out the current care
pathway
• Identify inhibitors & barriers
to change
• Identify areas for improvement
• Develop proposals for a new
integrated care pathway for patients with ARMD
WHAT IS AGE RELATED MACULAR
DEGENERATION(ARMD)?
• Acquired condition
- > over 60 years
• ‘Wet’ & ‘Dry’ forms
• Affects central vision
• Almost 1 million in England
• Commonest cause of
irremediable visual loss
• Accounts for 14% blind &
partially sighted registrations
( 50% for those > 65yrs)
• Limited credible treatment
options
ASSOCIATION BETWEEN
VISUAL IMPAIRMENT &…..
•
•
•
•
•
•
Increased mortality
Increased morbidity / falls / fractures
Increased road accidents
Increased anxiety & depression
Poorer self care & independence
Greater need for community & institutional
resources
• Social isolation - quality of life
• Loss of income
DEMOGRAPHICS
AMD
•1998 approximately 8.3
on people over the age
of 65 in England
and Wales
–4.3 million have impaired
vision
–AMD is the leading
cause in over 65s
By 2020
–A 25% increase in the
over 65 population is
expected
–Incidence of ARMD
expected to rise by 31%
AMD: A Growing Problem
• Burden recognised by government
– NSF for Older People
• Vision impairment is
an intrinsic risk factor for falls
– NICE: Recent guidance
on PDT for wet-AMD
• NICE to review new
treatments in 2005
• In meeting future
demand, service
will have to respond to
increasing patient
numbers and delivering new therapies
Current Services
• There are many good
points about today’s services:
– Access to angiography in
most (if not all) eye
departments
– Access to Argon laser in all eye departments
– Great awareness of AMD in general optical
services
– Prompt access for suspected wet AMD in most
secondary care sites
– In some centres access to LVA, LV1, social
services advice is almost one stop
Current ARMD Pathway
• Patient reports visual problem
• GP refers patient to HES
OR
• Patient is referred to an optometrist
• ARMD is diagnosed
• Patient is referred to HES via GP
• Fluorescein angiography carried out
• Any credible treatment option considered
• Patient managed by HES or by Low Vision Service
• Patient registered
• Referred for Social Service &
Rehabilitation support
Problems with Current Services
Can be a lack of collaboration /
communication between healthcare and
social service providers
Lack of timely diagnosis and ease of
access to treatments / social services
for patients with AMD
What do patients
want from future services?
•
•
•
•
Rapid and precise diagnosis in primary care
Access to medical retina specialists advice
Rapid access to treatment when appropriate
Access to LVA services to make best use of
remaining sight
• Understand risk factors
• Improved communication
between:
– Clinicians and patients
– Different service providers
• Further research
Need to Manage AMD Differently
Improve collaboration / communication
between healthcare and social
service providers
Ensure timely diagnosis and ease of
access to treatments / social services
for patients with AMD
The ‘NEW’ AMD Pathway
SELF
REFERRAL
REFERRED BY
ANOTHER CLINICIAN
OR CARER
OTHER SOURCE
PATIENT PRESENTS WITH VISUAL PROBLEM AND IS EXAMINED BY COMMUNITY
OPTOMETRIST IN TRIAGE CAPACITY – DIFFERENTIAL DIAGNOSIS
SYMPTOMS SUGGESTIVE OF ARMD
‘WET’ (NEOVASCULAR) OR
SUSPECTED ‘WET’
ARMD
DIRECT REFERRAL TO HES FOR
FLUORESCEIN AGIOGRAPHY
AND
FURTHER INVESTIGATION
NOT
ARMD
APPROPRIATE
CARE AS
INDICATED
‘DRY’ (NON-NEOVASCULAR)
ARMD
OPTICAL / OPHTHALMIC
UNTREATABLE
LOW VISION SERVICES
COUNSELLING
SOCIAL SERVICE SUPPORT
TREATABLE
ACCESS TO TREATMENT
REHABILITATION
BD8/LV1 AS REQUIRED
Summary of Evidence
• 2/3rds with vision impairment are over 65 years of age
• ARMD commonest cause of irremediable serious visual
loss in people over 65 years of age
• Macular degeneration - 14% of new partial sight & blind
registrations for working population (aged 16-64)
• Exponential increase in ARMD over the age of 75
• Demographic shifts in population - increase of
approximately 30% over next 20 years
• Reductions in contrast sensitivity, depth perception and
peripheral vision linked with risk of falls or hip fracture
• Visual impairment important risk factor for hip fracture
and falls
Inhibitors and Barriers
• Adequate Funding – fees, IT etc
• Human resources / recruitment
• Patient / Practitioner
Communication
• Competitive behaviour
• Lack of Inter Professional
Collaboration
• Lack of patient understanding
• Lack of trust
• Poor understanding / recognition
of the role of other professionals
Key recommendations for local
action
• Community optometrists encouraged to comply
with College of Optometrists guidelines when
examining older people
• Direct referral to the HES by optometrists should
be introduced
• Care networks involving all carers established to
ensure comprehensive care for
all patients within an integrated
structure
• Best possible patient care to be
the clear focus of all involved
Elizabeth Bates
Co- Director, Greater Manchester
Children’s Network
& Chair
Low Vision Services Working Group
Aim of Pathway
“A growing number of the most
vulnerable people in this country
experience a quality of life that is
significantly, but unnecessarily,
diminished for the want of basic,
relatively inexpensive health care”
(RNIB 1999)
Key Issues
• Vast majority of people with low vision are over
70
• Most people with low vision retain some sight
• Sight can be maximised by:
– prompt advice and counselling
– early assessment
– provision of appropriate low vision aids (LVAs) and
training in their use
• Effective low vision services can reduce
admissions to residential care
Current Low Vision Pathway
•
•
•
•
•
•
•
Fragmented
Wide variation re access & quality
Referral from optometrist (often via GP) to HES
Uni-disciplinary
Lack of information, signposting & awareness
Long waiting times
Initiation of LV services ONLY after
ophthalmological assessment
Proposed Low Vision Pathway(1)
• Emphasis on low vision services not
provision of low vision aids
• Led by Primary or Social Care
• Partnership Approach
• Providing Services which promote:
– Awareness
– Timeliness
– Accessible
Proposed Low Vision Pathway(2)
•
•
•
•
Establishment of a key worker model
Registration not a pre-requisite
Medical assessment not a pre-requisite
Services enable re-access and reassessment
• Better utilisation of relevant health & social
care professionals
Proposed Low Vision Pathway
Start
4. Service enables re-access
1. Patient referred to Low Vision Service
(LVS)
•Referral may be from secondary care, GP, social worker,
rehabilitation officer, community nurse, OT etc or may
be self referral
•Patient may have an LVI, RVI or CVI
•All patients are contacted by LVS within 10 working
days
3. Patient has follow up
visits as needed
•Visits may take place in the
patient’s home or elsewhere
•Visit will be by appropriate
member of the LV team
2. Patient attends LVS
•Service is seamless across health, social care and the voluntary sector
•A full sight test forms part of assessment
•Patient is given information on eye condition, entitlements etc as well as local services
• Counselling and advice on employment or education is available
•Spectacles, LV aids, advice (esp. lighting, contrast and size) and home adaptations are
discussed and made available as appropriate
•Referral to other areas of health and social care as needed, including certification
Recommendations
National Action
• Develop national
eligibility criteria & core
standards
• Review existing funding
streams
• Understand workforce
implications
• Develop generic training
programme
• Audit existing services
Local Action
• Develop local partnership
arrangements with
designated lead
officer/organisation
• Integrate LV assessment
into the Single
Assessment process for
older people
• Move to provision of LV
aids via a “loans” service
• Consider opportunities
offered under the new
GMS contract for LV
screening
Delivering Effective Patient
Choice in Cataract Surgery
Ann Wagner
Programme Director
West Yorkshire Patient Choice
Delivering Effective Patient
Choice in Cataract Surgery
• Choice and wider system reform context
• West Yorkshire Patient Choice Cataract
Pilot
• Opportunities and Challenges
What is Choice all about?
• Dept of Health policy to deliver more choice and
certainty to patients
• Starting with choice of elective care, choice will
eventually be rolled out to all service areas
• Starting with choice of when and where, choice will be
expanded to include choice of what and who
• Needs to be seen in context of wider system reform
agenda
• linked to financial flows – payment by results, agenda for
change, booking, e booking and NPFIT and plurality and
diversity agenda.
• A key enabler for choice is booking and e booking
Choice Targets
• From end April 2004, patients waiting over 6
months to be offered choice of at least one
alternative provider
• From January 2005, all cataract patients to be
offered a choice of at least two providers at point
of referral
• From April 2005, heart surgery patients to be
offered choice of hospital at point cardiologist
refers them to a cardiothoracic surgeon
• From December 2005, all patients requiring
elective care to be offered choice at point of
referral of 4 or 5 alternatives
West Yorkshire Patient
Choice Cataract Pilot
Community of Interest:
• 15 PCTs
• 5 Acute Trusts
• 4 LOCs
• Host PCT with DTC capacity and capability
• Clinical Engagement
• Supportive SHA
• Financial support of DoH
West Yorkshire Patient Choice
Cataract Pilot
Aim: to improve the patient experience by:
• Giving patients much greater influence over
treatment
• Reduce waiting times
• Increase activity
• Improve service delivery
• Challenge ways of working
Focus: day case cataract surgery at Westwood
Park DTC
West Yorkshire Patient Choice
Cataract Pilot
Choice Objectives:
• Targeting long waiters
• Choice in secondary care
• Choice in primary care
To support West Yorkshire Health
Community in delivering choice for all
West Yorkshire Patient Choice
Cataract Pilot
Developing clinical and patient pathways
• Process mapped existing pathways and practice
• Benchmarked against best and recommended
practice
• Considered options and where to put choice for
greatest benefit
• Agreed way forward including supporting
common information, referral forms, Optom fees
and clinical audit
Where do we offer Choice and Booking?
3 mth max
Choice
Booking
Optometrist
Outpatient
waiting list
3 mth max
Assessment
Inpatient/
Daycase
Treatment
Post Op
Assessment
Optometrist
Sight Check
• Who offers Choice?
• Who makes the booking?
West Yorkshire Patient Choice
Cataract Pilot
Opportunities:
• Improve the patient experience
• Strengthen community of interest
• Explore single site capacity expansion
• Test out national tariff
• Develop more effective pathway
• Take a proactive, patient centred approach to
evaluation and peer review
• Pilot choice
West Yorkshire Patient Choice
Cataract Pilot
Challenges:
• Corporate buy in
• Optometrists fees
• Putting choice into the pathway
• Loss of control
• Conflicting policies/ competing priorities
• Referral thresholds and discharge protocols
• Data and patient tracking
• Transport
• Not reinventing the wheel
“And should there be a sudden
loss of consciousness during this
meeting oxygen masks will drop
from the ceiling”
Contact Details
Ann Wagner
Programme Director
West Yorkshire Patient Choice
Tel: 07970 770708, 01274 322537
E mail : [email protected]