“It’s the one sense that patients would hate to lose”

In partnership with SpaMedica, OT spoke to two optometrists about the benefits of referring patients into independent providers for NHS age-related macular degeneration (AMD) treatment – from shorter waiting times for care, to the opportunities for learning that consistent feedback on referrals provides.

Experiences of AMD in the community

With an ageing population, practitioners are becoming increasingly used to seeing AMD in High Street practice. In fact, it’s predicted that by 2025 there will be upwards of three million people living with drusen in the UK, and 710,000 living with late-stage AMD.

AMD is becoming “more and more prevalent in daily practice,” Sandhya Gosai, optometrist at Boots Opticians in Chelmsford, told OT.

“I’m seeing more patients who are presenting with drusen,” she said. “Obviously, it’s my responsibility to explain to them what that is, how it can impact them, and how to try and slow down progression.”

Waiting times at her local NHS hospital eye clinic were already long and the staff were under a lot of pressure before the pandemic, and since then they have grown longer, Gosai said.

The option of referring to SpaMedica has been reassuring, Gosai said, adding that “as a clinician, it gives me that peace of mind that my patients are being seen to in a timely manner.”

She referenced a patient whom she treated before SpaMedica had a clinic in the area, who returned to practice after a referral because they hadn’t yet been seen by the hospital eye service.

“Since having this local facility, that has not been an issue anymore,” Gosai shared, adding that patients now “feel in safe hands, and like something has been done about this condition that potentially could affect their vision.”

Deepal Burgess, a locum optometrist in Lincolnshire and Cambridgeshire, agrees that there has been an increasing number of AMD referrals since the pandemic.

“Straight afterwards, there was a lot of delay in people coming to get help,” Burgess said.

This led to “quite significantly reduced vision for some patients, who thought they wouldn’t be seen, so they didn’t come in,” she shared.

Burgess added: “A lot of the elderly patients wait until they’re called to come in, instead of realising that if they have a problem, they can come in sooner. I think that’s a communication issue.”

The SpaMedica offering

Gosai first learnt about SpaMedica’s AMD offering through a continuing professional development evening where she was able to see the clinical expertise available. She was already familiar with the hospital’s processes, as she had regularly referred patients for cataract operations.

“We already had a relationship and awareness of how competently these patients were being dealt with, so I had no hesitation in sending my AMD patients to them as well,” she said.

NHS waiting times were also a key reason for referral into SpaMedica, as was the fact that hospitals are local to where patients live.

“They were able to see urgent AMD cases within a matter of weeks,” Gosai said. “Because I’d already established a relationship with them through the cataract referral process, I knew that they were in safe hands. They offered a high level of care to my patients.”

Burgess noted that the practices she works in also had their patients seen by SpaMedica two weeks after the initial referral.

Local relationships also help in terms of knowledge-sharing, Burgess said.

“I’m on the local optical committees in both Cambridgeshire and Lincolnshire, so having those connections helped me to understand what the whole range of services looked like and the timeframe,” she told OT.

“I've been to visit SpaMedica hospitals in both Peterborough and Newark, to see how they work.”

Knowing which days clinics are running is helpful in terms of knowing whether a patient more suitable to be seen by SpaMedica or by the NHS trust, Burgess said, and this will often influence her decision on which path to take.

Gosai noted that the locations of SpaMedica hospitals are a benefit, too.

“A lot of our patients, obviously, are elderly, and they have to rely on other people to take them to these appointments,” she said. “They’re having to ask relatives to take time off work, so if they're having to travel miles away, they might not be able to attend so regularly. It’s great that the hospitals are so local.”

Because I’d already established a relationship with them through the cataract referral process, I knew that they were in safe hands

The referral journey as a two-way process

OT is interested in hearing about the treatment journey for a practice’s patients, and how the referring optometrist is kept informed throughout the process.

Burgess explained that patient choice is key when she is processing the initial referral.

“In Lincolnshire, we have a single point of access referral, and they do offer choice on urgent referrals as well,” she said. “That’s a new thing, which is really helpful. I will discuss with my patients where they live, and which are their closest options. SpaMedica is quite often one of them. If the patient would like to go to SpaMedica, I always put that on the form, if possible.”

Communication is clear from the outset once a referral has been sent to SpaMedica, Gosai said.

She explained that she will email her referrals directly, and that confirmation of receipt and that the process is being actioned will come through as standard.

“Once the patient has been seen and they’ve had an assessment, I get a letter back from SpaMedica saying what they thought the situation was, what the management strategy is going to be,” Gosai explained. “Obviously that's a learning for me as well, on whether my original referral was accurate.”

Gosai believes that this level of communication has huge benefits for the primary care practitioner.

“It’s a real learning opportunity, to have those letters back. We don’t always get letters back from our clinics, but with SpaMedica we receive that letter for every patient.”

She added: “Often the GP gets informed about a referral, but the original referrer, myself, doesn’t get to know what else has happened to this patient. We don’t get to know about the management strategy, which we do with SpaMedica. That adds to our learning.”

Burgess agrees that this knowledge is “really important.”

“You need to know, firstly, whether you were right, because sometimes you are unsure when you’re sending these patients – is it wet AMD or not?” she said.

Burgess also finds that this communication offers clarity that helps with the care that she can provide, especially if a patient is unsure on the exact details of when they were seen or what the outcome was.

“A lot of the patients may not remember exact dates. They might say it was two weeks ago, but actually, they mean four or six weeks ago,” she said. “They’re not sure if they’re overdue, or if their follow-ups are on time.

“But you know exactly where they are, and whether it’s the right time to dispense them or refract them, if they need that. It’s good to be able to work out what we can do for our patients, knowing what they’ve already had done.”

She added: “If the patients don't remember and they come and see you, you can tell them where they are in their journey.”

AMD is a field that is constantly changing, Gosai said, with practitioners trying to keep on top of frequent new developments.

“We don’t always have access to that kind of information. But these are direct patients, who are having this treatment now,” she said.

This is also helpful for patients, Gosai said: “Having the letter in the patient’s file is really useful. If the patient came back and reported any changes, we’d have it there – what the patient has already been through.”

We don’t always get letters back from our clinics, but with SpaMedica we receive that letter for every patient

Patient choice and experience

OT is interested in finding out how practitioners explain AMD to patients, particularly if they are scared or worried about what the condition might mean for them.

“I try not to alarm the patient,” Gosai said. “Using the term AMD can make the patient panic, especially because they know AMD can be a sight-threatening condition.

“I like to say, ‘you have wear and tear changes at the back of the eye, over the part of the eye that you’re looking with.’ They seem to understand that more, and it doesn’t sound as dangerous as AMD. That’s how I explain it to them.”

She added: “It’s the one sense that patients would hate to lose. I get so many patients saying to me, ‘I can do without my hearing, but I can’t do without my vision.’ It has to be handled delicately.”

Burgess explained that she also describes AMD in terms of wear and tear, and that patients often joke about it happening because they are old.

In this case, she finds it important to reiterate that, although this might be true, it is still a serious condition. She emphasises that their referral should be quick, and that they should get back in touch with the practice if they don’t hear anything.

“It’s tough, because you don’t want to scare them too much,” she said. “But you do need to let them know that, when they get the call asking them for choice [of where to be treated], they need to answer the phone.”

When our practitioners see a patient with suspected AMD, how do they talk to them about the referral process? What key messages do they share, and how do they explain their options?

Burgess will present her patients with a list of potential options, and emphasise that, although one hospital might have the shortest waiting time, it might not be the best option if it is further away.

Making sure patients know that they will have to visit the hospital frequently is key, she said, as is reiterating the importance of picking up the phone to ensure that they do get the choice they want.

Gosai has fewer choices for referral in her area, with the local SpaMedica or the NHS hospital the two options.

“I don’t have that many choices on where I can refer the patient to, and I’m swayed by waiting times,” she said. “I don’t want to run the risk of referring to the NHS eye clinic, and not know how long the referral is going to take. I can't take that risk. My choice is heavily swayed to a shorter waiting time, and locality.”

Waiting times are also often the most important factor to the patients she refers, she explains.

“If it’s an urgent case, patients are willing to travel out further to get that treatment,” Gosai believes. “Getting that treatment in a timely manner is so important, because once the damage is done, it’s difficult to reverse. You have to catch that patient at the right time.”

If a patient is going to be treated at SpaMedica, Burgess makes sure that they know which day of the week the clinic is running.

This is helpful because although they might not know the exact date, it means they can plan to a certain extent.

If they need a relative to take them, “They can go home and make arrangements straight away,” she said, adding that providing information on parking is also helpful for patients.

Burgess added that patients she has referred whilst working in Newark value the fact that they see the same practitioner for their injections every time they attend the local SpaMedica hospital, and that they can have a joke with her.

“When I’ve visited the SpaMedica hospital, everyone, both the staff and the patients, all look happy,” Burgess said. “They always feel that they’re well looked after, and they feel important as individuals.”

Find out more about SpaMedica's AMD Service and the closest service to you and your patients here.