What I have learned
“There are significant benefits for everyone involved”
Co-author of the Getting It Right First Time (GIRFT) ophthalmology national report, Professor Carrie MacEwen, and lead ophthalmologist at Hinchingbrooke Hospital, Dr Chris Stephenson, discuss how optometry can alleviate strain on NHS ophthalmology departments
What did you identify during the Getting It Right First Time (GIRFT) visits?Professor Carrie MacEwen (CM): We found that units are working very hard in order to meet the increased demand for ophthalmology services over the last decade. That was not a surprise to us. We also found that many units are very keen to make a difference – in many cases, they were implementing different and new ways of delivering care to try to meet this demand. Our review mainly focused on the high-volume aspects of ophthalmology, including cataract surgery, macular and glaucoma work. We tried to concentrate on these areas as this is where changes are mostly being made.
How are ophthalmologists working with optometrists?CM: The focus was on the hospital eye service, so we weren’t able to meet up with community optometrists unless they were also working within the hospital, and that was a rarity. As far as the role of optometry is concerned, in some places it has already been embedded and is a critical and important part of the service being delivered. In other places, optometry played little or no part. The reasons for that were varied. Some optometrists were already busy enough providing community care; in other places tariff structures and IT systems were being considered; and in others the relationship between ophthalmology and optometry was in an earlier phase but was was being developed.
We found that units are working very hard in order to meet the increased demand for ophthalmology services over the last decade
What role can optometry play in alleviating strain on the NHS?CM: We’re very clear in the report that optometry and ophthalmology need to work much better together. That’s recognised nationally, but it is about developing important relationships at a local level. Working together to define the nature of contracting and improving this process is absolutely vital. Optometrists play a vital role in referring the right patients. Refining the referral process and making sure that patients can be discharged for post-operative care to be carried out in the community needs to be encouraged. Also, there needs to be more care in the community for patients with stable, low-risk, or non-sight threatening glaucoma and other conditions. Key to that is IT, as well as good communication with one other, which we outline in the report.
What are the barriers to change?CM: IT is one of the barriers and we’d like to see improvements there. Training is also important – the report outlines that training of non-medical eye care professional groups, which includes optometry, orthoptics and ophthalmic nursing, is going to be a key part in making sure new systems of care work.
We’re very clear in the report that optometry and ophthalmology need to work much better together
What happened during the GIRFT visit?Dr Chris Stephenson (CS): Our ophthalmology team met with the GIRFT team and provided feedback on how pathways, particularly for cataract surgery, are managed with the group of community optometrists we work with. They visited the department and looked at processes in clinics and theatres, as well as meeting with our lead optometrist, who coordinates the cataract referral programme.
How does Hinchingbrooke Hospital work with community optometrists?CS: One of the reasons GIRFT singled out Hinchingbrooke as one of the successful programmes is because of our strong network of community-based optometrists. We’ve developed that from the outset of the cataract referral programme 15 years ago. The network has evolved over time and it’s been key to the success of the programme.
There are limited resources at the hospital, so we developed working relationships initially with GPs and then optometrists, who the GPs handed responsibility over to for direct referrals into the hospital. If a patient was seen in the community by the GP and felt that they had a cataract or minor eye condition for referral they refer directly to their local optometrist. We have 90% of optometry practices in the area signed up. They have the authority from GPs to see and manage minor eye conditions, which reduces the number of referrals into the hospital. If they have a more serious problem or a significant cataract they can refer them on the pathway system into the hospital’s eye department.
One of the reasons GIRFT singled out Hinchingbrooke as one of the successful programmes is because of our strong network of community-based optometrists
How does the department triage patients?CS: Our in-house optometrist is fundamental in triaging patients that have been referred from the community. We have protocols for whether to accept those patients onto the list for cataract surgery. If they fall outside of those parameters then they’ll be booked into a consultant-led clinic for further assessment. In excess of 80% of those patients will be directly listed for cataract surgery.
How does it improve the patient experience?CS: It reduces the amount of visits a patient makes. If they are deemed suitable they will be referred directly onto the surgery list, so there is no additional assessment in the eye clinic before being listed. Senior nurses at a pre-assessment clinic will do biometric tests in the hospital two¬ to four weeks before surgery. If the surgery has proceeded normally and they are routine they will be referred for aftercare four weeks after surgery to the community optometrist that listed them in the first place. This provides continuity of care for the patient too.
Lead ophthalmologist at Hinchingbrooke Hospital, Dr Chris Stephenson
Why is it important that ophthalmology and optometry work together?CS: It keeps the patient out of the hospital so we’re not seeing huge numbers of patients unnecessarily, which takes up hospital time and resources. It makes the process more efficient and it will keep continuity of care for the patient in the community. As it is such a well-regulated process, the safety factor is excellent. We audit our outcomes annually and we’ve found that the visual outcomes and the complications rates are well below the national average. There are significant benefits for everyone involved, but primarily the patient.
Pictured is Hinchingbrooke Hospital