The urgent care clinics at Cayton Street were set up in November 2017 to run alongside the A&E department at Moorfields Eye Hospital.
They were established after the hospital recognised an increasing difficulty in consistently delivering the national four-hour A&E target due to growing numbers of patient presentations, with a rise in the numbers of breach days and an increased requirement for extra locum staffing in recent years.
Repeated clinical audits had shown that at least 30% of patients presenting to Moorfields A&E could be assessed more appropriately in planned urgent care clinics.
Initially, an urgent care clinic was piloted in 2016–17, running in the evening once a week. The clinic reviewed a defined cohort of patients who attended A&E with non-emergency conditions that required non-urgent secondary care review of patients referred from A&E triage to the clinic.
The pilot of the clinic demonstrated its safety in the management of patients in a more planned and controlled way through the service.
“Repeated clinical audits had shown that at least 30% of patients presenting to Moorfields A&E could be assessed more appropriately in planned urgent care clinics”
Up and running
Clinics now run at Cayton Street every weekday, either in the morning or the afternoon.
The clinics only see new patients, while patients seen who require other specialist input and management are discharged and referred as a new patient to the relevant service.
Patients are triaged to the clinics from A&E each day, or in the week before. They are offered either a same day appointment, or an appointment later that week. The urgency of the appointment is decided by the onset and severity of the presenting symptoms. Appointments are generally available the following day in urgent care clinics, which means that those with urgent, but not immediately sight threatening conditions, can still be seen promptly.
The five clinics are staffed by 18 optometrists. Each day four optometrists will work alongside a consultant ophthalmologist and two health care assistants, who help work up the patients.
A skilled workforce
One of the aims of the clinic when it was established was to expand the role of optometrists and to open up the range of conditions that optometrists have experience of managing and treating.
The majority of optometrists (78%) working in the clinics are qualified independent prescribers.
Working in other hospital eye clinics also means that many of the urgent care optometrists are able to bring with them an additional skill set to perform further tasks such as gonioscopy, scleral indentation, confocal microscopy, naso-lacrimal duct syringing and suture removal.
In addition, optometrists can measure systemic observations such as blood pressure and blood sugar as required. This helps in the diagnosis of conditions and reduces the number of unnecessary referrals from the urgent care clinics in to other services.
Those working in the urgent care clinics see a large variety of conditions ranging from the more expected conditions such as dry eye, blepharitis, vitreous detachments and cataract, to the less expected conditions such as papilloedema, optic neuritis and disc pallor.
“100% of conditions are being managed appropriately”
A recent audit of the clinic showed that 100% of conditions are being managed appropriately. Furthermore, 62% of conditions are managed independently by the optometrists in the urgent care clinic, while the remainder of conditions are managed jointly with the medic in the clinic.
In total, 82% of conditions were found to be appropriate for optometrists to manage independently based upon the current protocol. Since this initial audit, the clinic’s triaging system has been reviewed in order to improve this number further.
It also found that the average journey time of a patient in the urgent care clinic is 75 minutes, which is just under half the time (140 minutes) that a patient can expect to be seen and managed in A&E. Overall, 90% of patients are seen and discharged from the urgent care clinic in under two hours. No patients so far have breached the four-hour A&E national standard.
The current UK population is 66 million people and there are approximately 3000 UK ophthalmologists and 14,000 UK optometrists, with a further 700 qualifying annually. In addition, ophthalmology has recently been highlighted as the treatment specialty with the greatest number of attendances at 7.6 million visits in 2017–18. This raises the question of whether optometrists are an under-utilised resource and whether there is scope to increase the numbers of optometrists working in A&E services, either triaging patients out, or being employed in consultant optometrist posts in optometrist-led services.
“90% of patients are seen and discharged from the urgent care service in under two hours. No patients so far have breached the four hour A&E national standard”
The protocol for the urgent care clinics is due to be reviewed later this year, and the current audit has highlighted that there may be scope to broaden the list of conditions that optometrists in the clinic are able to review and manage independently. There is also the potential for the service to be expanded to be able to accept direct referrals from GPs and to become involved with local minor eye conditions services. It could also provide training to optometrists in the primary care pathway in order reduce the number of referrals made and increase management outside of the hospital.
In April, the Cayton Street clinic model, which also incorporates the optometry-led glaucoma service, received an award from Moorfields Eye Charity for its innovation and service improvement. On receiving the award, the Cayton Street clinics were recognised for providing quality care through a quick and efficient model, surpassing expectations and allowing them to be seen as a role model in the standard of care.
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