“We’re prepared for new ways of working”

What initial impact did the COVID-19 outbreak have on the ophthalmology services in the Royal Free Hospital?

Safina Rashid: Very quickly we had to look at reshuffling our service in terms of trying to identify the high-risk patients, keeping those on our clinic list and contacting the medium and low-risk patients to inform them that their appointments would be cancelled and rescheduled accordingly.

That was a huge project across our sites including Chase Farm Hospital, Barnet Hospital, Edgware Community Hospital, St Pancras Kidney, Diabetes and Eye Centre, Whittington Hospital and the Royal Free.

A few weeks into April, eye clinics at several of these sites closed and we faced co-ordinating the high-risk patients coming to the Royal Free, as well as the additional patients from these sites.

What changes were made to the services?

SF: The urgent eye care service became an open service. Prior to COVID-19, we didn’t really offer a walk-in, but would provide a service that was mainly sourced from patients that were referred from the GP or existing patients that had a query or problem.

We quickly set up an ophthalmology advice line which was there to try and support patient-based queries. This line was held by an orthoptist or optometrist who could talk through the concerns and queries and help triage and direct patients accordingly from there if we had a patient we were concerned with or needed to see face to face, they could be booked into the urgent eye care.

I can say from covering the weekend urgent eye care shifts that it has been a very different way of working. One particular bank holiday weekend, on the Saturday, we had a collection of cases of trauma, where patients had been knocked in the eye. That was quite an eye opener that showed how the lockdown at that time meant people were having to stay at home together and what impact that has on people’s mental wellbeing.

We were already bursting at the seams before COVID-19, so it’s going to be tricky now to have fewer patients in clinic and still meet that demand

How have colleagues within the department been applying their skills in new ways to support the changes?

SF: In the first week of April, our nurse colleagues were asked to be redeployed to the ward. It happened quite suddenly and meant myself and the team of orthoptists and optometrists were to be redeployed within ophthalmology, taking on the nursing role. They had been responsible for opening up the clinic, security of the clinic and organising support for the ophthalmologist, mainly around intravitreal injections.

Usually orthoptist and optometrists would be taking a more specialist role, but in this scenario we were covering everything to make sure the department was open and ready to start taking patients in at 8am.

This involved a bit of training as there were things we’ve not had to do before because we always had our nursing colleagues. Things such as dealing with an unwell patient or looking at imaging equipment, we may not have all been exposed to previously.

It was a quick learning curve for all the team to be able to do some of the ophthalmic diagnostic procedures and also the injection assisting procedure. I’m really proud of the team because there were so many changes and it was quite difficult, but everybody really pitched in.

What have been some of the more challenging aspects of the experience?

SF: Quality of vision is one thing that sits really uncomfortably with all of us. It is the fact we can’t do any cataract surgery as it’s not classed as being high-risk, but we know patients’ quality of vision can deteriorate and affect their quality of life, as well as their ability to do certain things.

It’s an uneasy feeling we have of this growing number of patients. We know, with all the previous hard work that’s been done by the optometry groups and all the studies that have shown, that we shouldn’t allow cataracts to mature. It’s probably like that in other specialities as well but for vision in particular it does feel a bit strange.

What might you take away from this experience and apply to optometry and ophthalmology services in the future?

SF: One of the projects we’ve been working on is looking at Attend Anywhere and telephone consultations. For the medium-risk patients, what has been interesting is seeing if we can do a few things over the telephone, which has been great.

We’ve managed to do quite a few video attendance consultations for patients in paediatrics, where the parent can hold the child and can cover one eye. The quality of the videos hasn’t been great consistently and neither has the audio, which is a shame, but I think we all feel as a working group that there is probably a place for this in ophthalmology. It would probably be as more of an in-depth triage, and wouldn’t be able to replace face to face.

I think we’re prepared for that slight change now and new ways of working where there will be an element of face-to-face, telephone and possibly video as well. We’re kind of getting ready for that now, perhaps more so than we would’ve done ever before.

We’re also looking at virtual clinics. Previously we would have thought these would be for the low-risk, but now we’re thinking we could move some of those medium to low-risk patients into the virtual clinic where they will go through a pathway of having a battery of tests. The consultant can review these and follow up with a telephone call and a letter.

What do you think is next for the department?

SF: Now it feels like we’re taking a big deep breath. We know we’ll have a growing number of patients come autumn time and we’re planning how to redeliver services, how that’s going to look and the new ways of working for that. We’re also looking at the telephone and virtual consultations and how we’re going to spread these patients across the working week and maybe the weekend as well.

I think it will be a bit of a difficult one for all specialities really. We were already bursting at the seams before COVID-19, so it’s going to be tricky now to have fewer patients in clinic and still meet that demand. Though we’re going to try to streamline, I think we’ll have to look at this new pattern of working to address that. It is a little bit daunting to think of.

We’re constantly mindful about the patient’s vision and the impact on their quality of life, as well as the impact that vision has on other problems

Could you tell us what it was like to be redeployed within the optometry and ophthalmology services?

Sheena Patel: It was a steep learning curve. I was redeployed from the site at the Whittington. In this new situation we had to learn the logistics of when opening up and organising the clinic – you need to know your clinic well.

We were learning all the things the nurses do – such as injections, which is something we never really look at from the nursing point of view. It completely opened all our eyes to how much work is involved around having the clinic running smoothly and effectively.

It all happened quite suddenly, the nurses were redeployed and it was a bit daunting at first, but everybody stepped up and worked as a team which was really good. When we do our specialities we’re very used to just doing those roles and spending all day doing that, but in this situation, if you didn’t know something then everybody just asked each other and helped each other out.

How has this experienced compared with your typical day-to-day role before COVID-19?

SP: Normally I would have been doing a specialist clinic in diabetic retinopathy and glaucoma, sticking to my own clinic list. When this change happened, it meant we were working alongside all sorts of different specialities at the same time and there was a lot of assisting in the clinic. I would be doing imaging with a lot of the machines I hadn’t actually used before myself, so we were taking these images and making sure we had good images. We were trying to do as much as we could to help out the consultants from that point of view. I was also helping assisting intravitreal injections as well, something that was completely new to me and very different from my day to day.

I would sometimes look after the helpline. This was across the board, so we could be sorting out issues that might not be to do with ophthalmology, such as logistical issues about transport or any concerns they had. It became much broader when you were on the phone, listening to the concerns they had or what they needed help in.

I have also been triaging my normal clinics and helping out with the clinics I would have been involved with in the Whittington with the high-risk patient team.

We have an audit for the high risk patients to make sure that none are lost to follow-up at this time, finding out the reasons why they didn’t attend appointments or why they were rescheduling. There are a lot of high-risk patients when you start putting them all together and it does highlight how many vulnerable high-risk patients we really have. We wouldn’t think of it in that way normally, but here we’re trying to prevent sight loss. It’s really important and though they’re worried about the situation, they’re also housebound or don’t normally have much mobility to go out so they really do rely on their sight for day-to-day hobbies and getting by.

We’re constantly mindful about the patient’s vision and the impact on their quality of life, as well as the impact that vision has on other problems.

Are there areas of this experience that you will take away beyond the crisis?

SP: I think a lot of the things we’ve changed, in being more mindful of the high-risk patients and medium and low-risk patients, we’re going to take that forward. We’ve also learnt that we could do a lot over the telephone that we didn’t realise we could do. It doesn’t have to always be face to face. I think going forwards it is going to make it easier to do certain things that we could just do over the phone or video.

This experience has definitely accelerated looking at streamlining. I think triage has been a really good thing; it has made us think a lot more about it and I think if we triage them like we do now, it makes it much easier when we organise the face-to-face appointment. Then I think it would be easier for us to try and do more one-stop clinics.

What has the experience of adapting to new roles and teams meant for you?

SP: Though it was a bit scary and daunting at first, it wasn’t really a negative experience. Everybody just took it in their stride. Spirits have been high and that’s really been lovely.

I think we’ll take away the teamwork and better understanding of each other’s role, like knowing what happens behind the scenes for most of us, and how quickly we can adapt and change. It doesn’t have to take time to change the way we’re going to work. I think that’s going to be beneficial and you could apply that knowledge to lots of different things.

With the team in ophthalmology redeployed, it’s been interesting to hear what they’re experiencing, what they’ve changed or is working for them. Because we’re normally on different sites, it feels like we’re a really close knit department and I’m actually going to be quite sad when I leave to not see everybody.