Part II: Issues and Recommendations
This section of the report presents, in summary form, the issues which have been identified during the review process and proposes recommendations for action. These should be considered in the context of the principles agreed at the outset of the review: person centred, intelligence led, asset optimised and outcome focused. The review also seeks to recognise the recommendations of the CMO report on Realistic Medicine, that only tests and treatments that are clinically indicated and proven to affect overall care are recommended. While the issues are presented under a number of separate headings, many are closely interlinked.
1. Public perception and awareness
As demonstrated in the earlier part of this report, the number of people accessing eye examinations has increased significantly since the new GOS arrangements were introduced in 2006. There is also greater understanding of the role of the community optometrist as the first port of call for people with eye problems. Nonetheless, the evidence from the General Optical Council's 2016 Public Perception Survey and from the work undertaken for the Review by the Scottish Health Council is that there is still a need to promote wider appreciation of the importance of eye health and that the eye examination and associated services provided by community optometry are a core part of the NHS primary care system. The information on access to services analysed for the Review by Practitioner Services ( PSD) from GOS claims confirms the concerns of the profession that those living in challenging circumstances are less likely to attend for regular eye examinations, and thus may fail to benefit from the early detection of sight threatening disease.
It is recommended that Scottish Government consider with the profession a fresh approach to national eye health awareness, the vital role of community optometry in the early detection of eye disease and, where locally arranged, as first port of call for unplanned and emergency eyecare, and the needs of those people who may be most at risk. This should be co-ordinated with more local campaigns targeted particularly at harder to reach communities, supported by local networks involving both the statutory and voluntary sectors, and the development of new ways of working to promote accessibility.
2. Interdisciplinary and interagency working
The changes which have taken place in community eyecare since 2006 have heralded significant improvements in the better integration of community optometric services within the wider health and social care systems. This is demonstrated, for example, in primary care by general medical practitioners positively encouraging patients to access optometry for all types of eye problem, and in the wide range of extended care schemes which have developed across Scotland through the joint efforts of community optometry and hospital based ophthalmology services. The recently established Integration Authorities provide a focus for even wider integration, including with the voluntary sector which has a vital role to play in supporting people with eye problems.
It is recommended that, as part of their planning and commissioning, Integration Authorities should consider the full range of eyecare needs of their communities. They should encourage close collaborative working not only across the statutory services to ensure the most effective use of professional skills and resources, but also with the voluntary sector. That sector via the Scottish Council on Visual Impairment (including organisations such as RNIB Scotland and local societies) can offer practical and emotional support, including, for example, peer support and community networks, mobility and rehabilitation services, counselling, employment and welfare, and specialist services for those with complex needs. There is also an opportunity to raise awareness across the health and social care professions as a whole of the impact of sight loss.
3. Primary Care Ophthalmic Services
The revised arrangements instituted in 2006 substantially changed the nature of the services provided by community optometry, and the very positive impact on increasing the management of eye conditions in the community has been documented in the earlier part of this report. However, there are concerns that the system has had some unintended consequences. The GOS arrangements are seen as promoting a "tick box" approach focused on ensuring that claims are made for the relevant fees rather than supporting a needs-led, patient centred approach. This is contrary to the approach now advocated in the Realistic Medicine movement which focuses on promoting patient centred care, reducing duplication and limiting harm through unnecessary tests and interventions. In some areas of Scotland, additional services are provided under the GOS banner which are not replicated elsewhere, leading to a disparity in what patients can appropriately expect from a nationally negotiated and defined service.
It is recommended that Scottish Government should discuss with the profession a revised national framework for GOS, to be provided by all listed optometrists, which has a focus on patient need and greater flexibility for professional judgement. This would also include the potential to review, in the light of international evidence, the frequency of eye examinations for those at minimal risk, and the nature of the primary and follow-up examinations for those with specific clinical conditions. Consideration should also be given to developing a system that better reflects the level of care provided, in particular where patients have complex needs or disabilities. Any new arrangements should be subject to full audit and review.
Despite the fact that optometric practices in Scotland are, in geographical terms, readily accessible, the actual use of services shows that people in disadvantaged communities and those from certain ethnic minority groups have not accessed services to the same extent as others, leading to continued inequalities.
It is recommended that any revised system should seek to target better those whose needs may currently not be met, supported by the targeted information and networks referred to above.
There has been duplication of effort across Scotland in some of the administrative functions which support the system locally and nationally. Dispensing opticians, who are key members of the community optometric team, are not currently included in local Ophthalmic Lists, and thus excluded from local clinical governance arrangements.
It is recommended that support be given to territorial Boards through national listing of optometrists and dispensing opticians (as is currently being proposed for other primary care contractor groups). There are other functions, such as dealing with discipline and GOC cases, that would benefit from greater central co-ordination.
4. Enhanced Optometric Services in the Community
As shown in Annex B to this report, a number of "enhanced" services have been implemented in various ways in several areas of Scotland, in addition to "core" GOS, with a range of different funding mechanisms. The evidence gathered from these initiatives demonstrates additional benefit both for patients whose care is delivered wholly within a community setting, and also for those patients whose care is provided in various ways between community and hospital based care (see 19 below). In most cases, these enhanced services are provided by a subset of designated optometrists/practices in any one area, and they have generally undertaken additional training in order to satisfy local accreditation arrangements and to provide ongoing quality assurance. The work undertaken by the Scottish Government Access Team on the National Ophthalmology Workstream, in co-operation with ophthalmologists and optometrists, has demonstrated how such schemes can best be put into place and sustained. In addition, over 142 optometrists have undertaken the independent prescribing course, and are now able to prescribe certain medications; this puts optometry in a prime place to support enhanced services as part of the wider primary care team.
It is recommended that national evidence based guidance be used to facilitate the care of relevant patients safely in the community. The Access Team's evidence, SIGN 144 (Glaucoma referral and safe discharge), and established local schemes supporting, for example, anterior eye conditions, post-surgery cataract patients, ocular hypertensives and low vision services, should be available across Scotland. A key component is to define the associated information needs of optometrists and ophthalmologists. It will be for local areas to determine the best way for these services to be delivered, taking into account local circumstances such as rurality, through locally funded contracts with designated and appropriately trained and accredited optometric practices, and agreements with ophthalmology services. These local systems should include the ability to cross refer between optometrists to ensure that patients of all practices have access to the relevant community based expertise. It is also suggested that, in order to support more effective continuity of care and exchange of information across primary care and with hospital services, the principle of those patients with specific ongoing conditions having a "named optometrist/practice" should be explored, supported by a system of voluntary registration akin to that which already exists in community pharmacy for the pharmaceutical care of patients with long term conditions. This approach could also be extended to the "core" optometric services for those with continuing care needs.
5. Diabetic Retinopathy Screening
The national programme provides annual retinal screening for people (aged 12 and over) with diabetes. It is underpinned by nationally agreed standards which promote accessible and equitable delivery of the service across Scotland. A new IT system is planned for 2017 to deal with future screening needs. As a national screening service, it is separate from the services provided by community optometry (with the exception of Ayrshire and Arran which locally funds optometrists to carry out this work), and many diabetic patients find it difficult to understand why they have to attend two separate services for their eyecare needs. Community optometrists also see an opportunity for better sharing of information.
It is recommended that, in the implementation of the new screening system, patient information makes clear the benefits of this separate national system, and that there is further exploration of the potential for better sharing of information with community optometrists. Opportunities to reduce duplication of care should also be explored.
6. Care Homes and Care at Home
Many residents of care homes and a number of people who are receiving care at home have continuing and sometimes complex eyecare needs; they include some of the most vulnerable patients. At present, most of the optometric services in care homes are provided by a small number of "specialist" practices, and there is little monitoring of the quality of service delivered. In addition, the services are generally provided in isolation from the other health and social care needs of the residents. The same issues apply to some extent to those receiving care at home, depending on the arrangements in local areas.
It is recommended that Integration Authorities should work with local care home providers to ensure that the quality of optometric care for residents is appropriately monitored and co-ordinated with the other primary care services. Similar arrangements should apply to optometric services delivered to patients receiving care at home. Enhanced services should also be available in the same way as to the rest of the community. If a service is unable to be delivered through the normal route, there is the potential it could be provided by directly employed optometrists using a model similar to the Public Dental Service.
7. Low Vision Support Services
The recent review undertaken for Scottish Government demonstrates the significant effect that low vision can have on people's physical and mental health. Appropriate provision of low vision aids can support a person's independence within the community, reducing their reliance on other support services. The review showed the very patchy provision across Scotland, with often poor access and lengthy waiting times. Integrating the provision of low vision aids with other community support services dramatically enhances the success of the model, combining community, social care and voluntary providers. Those models which are seen as particularly successful in meeting local needs in a cost effective way include the all Wales service, and community based schemes such as those in Ayrshire and Arran and Lanarkshire.
It is recommended that the conclusions of the Low Vison Services review, which demonstrate the value of a well organised community based model with clear pathways, should be taken forward by Scottish Government, in partnership with the statutory and voluntary sectors, in order to secure more equitable and accessible services across Scotland.
8. People with Complex Needs
Adults, young people and children with complex needs, specifically those with learning disability, autism, dementia, and stroke, are significantly more likely to have serious sight problems, may have communication difficulties, and have a range of issues impacting on their physical and mental health and wellbeing. A number of support services exist in various forms across Scotland which can provide:
- A functional vision assessment to provide information on what useful sight a person has and how the person uses their vision in everyday life. This can primarily be carried out in the community.
- A personalised vision passport which captures information of their vision, mobility, sensory needs to inform and influence support plans. This also provides information that can support an optometrist at a clinical eye examination.
- Practical solutions and support strategies for living with sight loss and identifies and engages with professionals and carers supporting people with complex needs.
- Advice, information and signposting and supporting access to eye care services and other services and products.
- Peer and volunteer support confidence building and self-management programmes.
It is recommended that Integration Authorities work with the voluntary sector to ensure delivery of these types of support services in local communities. Any review of GOS might wish to address the increased level of time and expertise to provide services to those with complex needs.
9. Primary/Secondary Care Interface
This review has recognised that, while the 2006 GOS arrangements have had a significant effect in providing services to many patients who would otherwise have gone to hospital, or have ensured that there is more effective care shared between community and hospital, there continues to be significant pressures on the specialist services. As mentioned above, the work of the Access Team on the National Ophthalmology Workstream has demonstrated how a re-engineering of systems can create capacity by utilising all the resources across primary and secondary care. Key elements in underpinning this include effective IT links through the Eyecare Integration Programme (see 10 below) which support continuity of care through referrals, discharge information etc., and the removal of unnecessary duplication of appointments, tests and investigative procedures. A dedicated telephone helpline can also support more confident clinical decision making in the community. In some areas, a key factor in enhancing the most effective use of both primary and secondary care resources has been the creation of a formal Network, led jointly by optometry and ophthalmology.
It is recommended that the conclusions and recommendations of the report from the National Ophthalmology Workstream should be allied to the recommendations from this review, and taken forward together by Scottish Government in partnership with the service. Implementation, suitably resourced, needs to be seen as a partnership between primary and secondary care interests. Specific examples of services where immediate benefits can be realised include glaucoma referral refinement and safe discharge of ocular hypertensives (implementing SIGN 144) and post cataract follow up.
10. Data and information
It is important in any care service to ensure that there are robust data systems and information exchange mechanisms to support effective clinical care, planning, communication and efficient administration, and that the appropriate IT systems are in place. A key element in this has been the Eyecare Integration Programme which has sought to support clinical communications between community optometry and hospital services, and IT links between optometry practices and PSD. Both aspects have been slower in uptake than planned, not least because of the need to resolve a number of technical issues. While electronic referrals from optometry to hospitals are increasing, the system does not provide effective support for electronic communication back from hospitals, a potentially key element in promoting continuity of care for patients. Similarly, the transmission of electronic claims to PSD has been patchy and reviews by ISD of the data submitted on GOS claims have demonstrated concerns about the accuracy of the clinical information. Similar concerns exist about the hospital ophthalmology outpatient data, where the diagnostic and follow up data required to plan and manage services safely are not being gathered. The development of a new data warehouse in ISD planned for 2017 will bring significant opportunities for better use and linkages of data, but only if the data input into the system are accurate.
It is recommended that the Eyecare Integration Programme should ensure issues affecting uptake by optometrists, whether technical or otherwise, are addressed, and that support is locally provided to enable the systems to operate effectively. In addition, the importance of accurate completion of the clinical sections of the relevant GOS forms (which could usefully be revised as part of an updated GOS framework) should be stressed to all listed optometrists. Greater sharing of test results ( e.g. retinal photographs, visual field plots) and two-way dialogue on treatment planning between optometrists and ophthalmologists would produce significant improvements in efficiency and clinical effectiveness. Consideration should also be given to the sharing (with consent) of relevant patient information from the Emergency Care Summary with community optometry.
11. Clinical Governance/Quality and Monitoring
The information referred to above is a key element in reviewing the nature and quality of the services provided, both within community optometry and in the interface with secondary care. In addition, appropriate and targeted education and training (see 13 below) are important contributors to maintaining and improving standards of care. The current practice inspection scheme for community optometry is almost exclusively focused on the physical and equipment aspects. Some of the specifications for extended services in some areas set out quality and audit requirements, but this is not universal.
It is recommended that any revised framework for GOS and service specifications for enhanced services should include relevant quality markers that can be readily reported and monitored. The practice inspection system could be usefully extended in scope to review and support quality improvement in practices (as with other primary care contractors), including review and support of the training and CPD of the practice workforce. The local Optometric Advisers, which should exist in all areas, could also have a broader role in supporting clinical governance at local level and in working together as a Group to support national developments.
While there is detailed information about the distribution of optometric practices across Scotland, there is very little information about the workforce within these practices. There is increasing interest in securing better workforce data in the primary care contractor sector (as well as in the managed services) in order that there can be more effective planning for the future particularly as services become more community focused to meet local needs.
It is recommended that Scottish Government should work with the profession and Public Health Intelligence ( PHI) to define the relevant workforce data needed and find ways of gathering this on an as required basis. This will fit in with the Scottish Government's commitment to deliver a national workforce plan for health and social care services. The role of dispensing opticians should also be considered to support patient care and deliver a quality service as part of an overall workforce review.
13. Education and Training
There are repeated references in this report to the importance of education and training as a key underpinning of service delivery and quality. It is recognised that the General Optical Council ( GOC) is undertaking a UK wide review of future requirements for continued registration, and this will continue to provide an important baseline. The 2006 changes brought additional requirements for community optometrists in Scotland to provide professional assurance of standards and quality. NES has continued to develop a wide range of well regarded, supporting education and training activities; these have been taken up by the majority of, but not all, optometrists.
It is recommended that, in any future changes to GOS and for enhanced services, appropriate accredited training packages coupled with robust assessment are put in place. These should be seen as formal and on-going continuing professional development requirements for optometrists who provide NHS care in Scotland to support a consistently high quality and safe service. As part of this, consideration should also be given to providing protected learning time (as happens currently in general medical practice) to assist optometrists and their teams to benefit from the educational support and undertake any related quality improvement initiatives. The undergraduate course and the pre-registration year in Scotland also needs to reflect adequately the care requirements of the qualified optometrist. Consideration of more clinical training, leadership and management skills, wider patient health needs, multi-disciplinary working and clinical governance should be key elements. Interdisciplinary education and training with medical and other care professionals can bring significant benefits in shared understanding, trust and patient benefit.
Since 2006, significant investment has been made both through direct Scottish Government funding and by individual optometric practices in ensuring that the appropriate equipment is available to provide the relevant services and meet specific patient needs. The most recent central investment was in pachymeters for all NHS practices. A number of optometric practices now have Optical coherence tomography ( OCT) facilities, presenting an opportunity for extended care in local communities.
It is recommended that future developments in community based eyecare should include consideration of any related equipment requirements. Appropriate technology will also be required to support increased use of tele-health developments.
The recommendations in this report should be seen as a coherent package, but it is recognised that implementation must be prioritised and phased in a realistic way to reflect the potential resources available and capacity issues within stakeholder organisations. It is also important that they are set within the wider Scottish Government's transformation agenda. They should be taken forward in partnership with the relevant professional and patient interests and with the local statutory and voluntary organisations who can best effect delivery. It will also be important that specific measures of outcome and impact, including service use and access, patient experience and clinical audit, are agreed as part of the implementation plan.
Email: Liam Kearney
Phone: 0300 244 4000 – Central Enquiry Unit
The Scottish Government
St Andrew's House