National ophthalmology workstream: hospital eye services

What is the problem?
New treatments/drugs for previously untreatable conditions - (e.g. Wet Age Related Macular Degeneration);
Ageing population & changing expectations;
Propensity to long-term-conditions;

Increasing demand for return outpatient appointments in particular as a consequence;
Inadequate capacity to meet that demand;

Limitations of physical capacity;
Bottlenecks within secondary care patient flows;
Inadequate workforce - Consultant ophthalmologist vacancies within NHSScotland.

What are the existing initiatives/developments?
Eye Care Integration programme
Ophthalmology Short Life Working Group (to November 2013)
See Hear Initiative
SIGN Guidelines for Glaucoma
Scottish Vision Strategy
Cross-Party Working Group on Visual Impairment;
NES Training Strategy (Learnpro)

Alternative drug/injection treatment, potentially requiring less return visits
Upskilling of AHPs/Nurses - trained to deliver IVT injections;
Enhancing optometrist skill set in community

What do we know about the problem?
Inadequate output of overarching data to inform capacity planning;
Inadequate output of sub-specialty data to drill down;
Results in artificial variation:

clinic templates not set up optimally (number of new: reviews; timeslots);
Booking approaches to return outpatient appointments not consistent;
Frequent disparity between requested and actual date of return appointments;

Resource constraints
Physical accommodation /equipment
Manpower numbers and skill mix (at all levels)

What are the recommendations?
Capture real-time information to sub specialty level to inform strategic and operational decisions

Effective booking processes and training which acknowledge sub specialty variation and are responsive to safe patient care

Flexible use of accommodation (flexibility of access & timings);

Update consultant job plans to reflect demands on each service - improve attractiveness of consultant posts

Up-skill AHPs / nurses (e.g. IVT injections) and consistency of post grading

Strengthen work across primary/ secondary care interface (appropriateness of care settings).

Improve primary care optometrists training

Reduce number of patients returning to secondary care for monitoring by consultant clinicians (e.g. OHT). Use modern technology to help improve patient pathways. Ophthalmic technicians to release 'trained' time for skilled activities.

Philosophy: Deliver timely safe and effective patient centred treatment to ophthalmology patients across Scotland

What are the aims? National Framework for Change
Balance capacity with demand sustainably
Streamline pathway(s) that are most appropriate to the individual
Appropriately-upskill workforce, working in right settings

What is the plan?
Working with a range of key stakeholders across the primary/secondary care interface to deliver a balance of capacity with demand sustainably by smoothing pathways & variation, and systems & processes, using the right care professionals in the right setting, by:

• Creating the conditions and profile nationally
• Articulating what 'good looks like'
• Clarifying the framework / focus / workstrands - i.e. 'what' needs to be improved
• Empowering and working with stakeholders - i.e. 'who'
• Helping with the 'how' and avoiding reinventing the wheel
• Supporting co-production - sharing and networking

Referrals into secondary care: efficient referral management / pathways

Managing Demand into secondary care:

• Adhering to 5 referral protocols from primary care
• Training optometrists in assessment and referral criteria
• Consensus on referral thresholds
• Consistent information/work-up within primary care to promote timely assessment/intervention in secondary care
• Advice-only protocol and feedback on quality of referrals

Reduction in avoidable referrals;

Maintain high conversion rates to treatment/intervention;

Secondary Care Flows and Processes: efficient and effective capacity utilisation

High-level queue management / capacity management:

• Optimise use of available capacity;
• Reduce and optimise the number of sub-specialty queues;
• Appointment scheduling and queue shape (treat-in-turn)
• Smoothing variation (in capacity and demand)
• Optimal queue size and balance (remove backlog once-only)
• Balance capacity with demand sustainably
• Plan and manage systems, flows and throughput (trajectories)

Seamless journey - reduction in waiting times through having a system in balance

Standardised processes for hub or departmental booking.

Tailoring capacity to ensure adequacy and timing of appointment slots (consultant recruitment; job plans; sub specialisation).

Ensuring that provision is met (communication; transport; access) to support visually impaired patients attendance.

Contribution to NHS Education Scotland Learnpro suite

Operational clinic management / Standardising booking processes:

• Advanced training for admin staff re specialty-specific clinic booking requirements; standard operating policy, list validation
• Ensure triage to appropriate clinic first time (general or sub-specialty level); pooling
• Review clinic structure (including trauma; daily rapid access clinics; one stop clinics; specialty clinics; virtual clinics; 7-day working, cross Board working);
• Review clinic templates to support demand patterns; treat in turn; cancellations/ DNAs/ CNAs; appointment reminder system

Patient communication:

• Supplying information to patients in a format suitable for people with visual impairment
• Learnpro module for staff working with patients with sensory impairment

Follow-up /surveillance flows:

Streamlined systems and alternative models for follow-up

Managing return slots successfully:

• Review balance of new and return slots in clinic templates;
• Weekend clinics / virtual clinics undertaken by HCPs/Nurses
• Use return holding list to manage timeframes for returns

Make full and effective use of clinic capacity to smooth journeys.

Reduce bottlenecks/long waiting times

Patients should not routinely attend OP clinics for post-cataract follow-up within secondary care

Introduce alternative models for surveillance to reduce follow-up slots needed within secondary care by:

• Influence and minimise expectation of multiple return appointments, but recognise the need in certain long term conditions
• Timely virtual review / telephone call in low risk/minor conditions.
• Community optometry follow-up e.g. post-op cataract; - manage appropriate patients in primary care by optometrists
• Use clinical outcome data to identify other pathway opportunities

Extended roles for nurses/ HCPs
Secondary care

Up-skill nurses/ HCPs to perform intra-vitreal injections for diabetic retinopathy and wet macular degeneration:

• Clarity/consistency regarding job descriptions
• Appropriate training / skills' mix for service delivery
• Establishment and consistent use of local evidence-based protocols

Train HCPs through recognised programmes to assess and, in some instances, treat patients with chronic ophthalmic diseases

Working as part of the multi-disciplinary team in face to face, community or virtual clinics

• Free consultant capacity to undertake duties at higher end of competencies.
• % of injections performed by:

• Medical staff
• Nurses
• Other HCPs

Numbers of patients seen with glaucoma, diabetic retinopathy, AMD within secondary care

Extending the remit of optometrists / orthoptists
Primary Care

Extending the remit of optometrists / orthoptists

• Availability/utilisation of optometry bank and therefore enhanced levels of experience through 'in-reach' work in acute care setting
• Up-take of MSc course in optometry e.g. glaucoma patients (Queen Margaret University) and consequently up-skill optometrists in performing level 2 functions in primary care/ community setting

Extend optometrist role in delivering shared care

Extend multi-disciplinary team input in order to free consultant capacity to undertake duties at higher end of competencies.

Strengthening tertiary / local service networks
Specialised care

Delivery of specialised procedures:

• Robust regional planning, service configuration and pathways;
• Ensure complementary skills mix and competencies in low volume/highly specialised procedures.
• Focus delivery of high volume procedures in local DGHs.

Delivery of high volume procedures in acute setting and specialist procedures in tertiary setting.

Maintaining competencies - centre of excellence