Optometrists are responsible for the majority of referrals of patients for cataract surgery in the UK and have the necessary skills to investigate the clinical and functional needs of these patients, both before and after surgery. In most cases there is very little "value added" by the patient being seen by the GP before referral to the hospital, and so direct referral is a straightforward option acceptable to the majority of ophthalmologists and GPs. Working to locally agreed protocols optometrists can also evaluate the clinical and social needs of patients to ensure that the patients with most need are referred at the optimum time for surgery, either to a one-stop or two-stop cataract service in the secondary sector. Some ophthalmologists may be uncomfortable with a one-stop service, where they see the patient for the first time on the day of surgery, but a two-stop system, with patients pre-assessed can be a viable option. If this is shown to work well, then a move to a one-stop system can be considered. The whole approach to streamlining the care pathway should be considered from the point of view of the patient, to allow this care to be delivered at a time and place convenient to them, where this does not prejudice clinical safety.
In redesigning this process there should be involvement of the whole care team, which will include ophthalmologists, GPs, optometrists, nurses, management from both the primary and secondary sector, hospital clerical staff and patients. It is important for there to be common ownership of the scheme. Any new scheme would need to be financially viable for all parties but recognised that moving care away from the secondary sector will not in itself produce cost savings. If more surgery is to be undertaken by freeing up "ophthalmologist slots" in the secondary sector then the overall costs will rise, but the unit cost of each patient will be reduced.
There is little point in "reinventing the wheel" and so the protocols, forms etc. from existing schemes can be used, but in line with the policy of ensuring local ownership, these may need to be modified to suit local needs, circumstances and opinions. Click on the pdf files on the bottom of the page for further information on the background and development of cataract care; also for examples of cataract schemes.
'Choose & Book' Programme for Direct Cataract Referrals
From December 2005 patients needing elective treatment were offered a choice of four or five hospitals once their GP decides that a referral is required within the new 'Choose & Book' system. The choice could be NHS trusts, foundation trusts, treatment centres, private hospitals or practitioners with a special interest operating within primary care. The theory was that as well as choosing where they go, patients would be also able to choose when, thanks to a national electronic booking programme. Appointments can be made at the GP surgery, by calling a contact centre, online and eventually via digital television. Optometrists were involved in an accelerated version of the programme, applying to cataract referrals only, from January 2005. Primary Care Trusts were expected to offer a choice of at least two providers for cataract surgery, increasing to a choice of 4/5 providers by December 2005.
Direct referral, if managed and refined properly, has been shown to not only help reduce hospital waiting lists, but also to improve the efficiency of patient care. This is welcomed by the profession but it is important that Primary Care Trusts consult with Local Optometric Committees before introducing new arrangements for optometrists. Caract assessments and direct referral do not fall within the GOS remit and therefore need to be negotiated as separate items of service. The AOP issued advice for practitioners on the 'Choose & Book' policy and the way in which it was meant to involve the profession. This advice can be viewed in pdf format at the end of the page. The Department of Health's policy framework for choice and booking can also be viewed, as can its draft guidance to Primary Care Trusts entitled "Cataract Choice Guidance".
If you wish to view further information 'Choose & Book' on the Department of Health's website, please click on http://www.dh.gov.uk/PolicyAndGuidance/PatientChoice/Choice/fs/en
You can also access a dedicated, 'Choose & Book' website by clicking on http://www.chooseandbook.nhs.uk/
Do Once and Share (DOAS) Cataract Project
For information on this NHS-funded project, please click on the link below (there were also DOAS projects for diabetes and glaucoma, which you will find details of in the Diabetes and Glaucoma sections of this website):
http://www.rcophth.ac.uk/about/college/doas-cataract
