Promoting the Easy Eye Care Pathway to patients and practices

Could you give some context on the Easy Eye Care Pathway, and outline where it stands at the moment?

Trevor Hunter (TH): The Easy Eye Care Pathway was conceived in 2013. It was the Local Optical Committee Support Unit (LOCSU), SeeAbility, the Royal College of Ophthalmologists and Mencap, getting together to try and find a way for patients with learning disabilities to be seen in community practices, rather than not being seen, which is the worst case scenario, or being seen via referrals to hospital, when really all they need is a sight test. 

These patients need an individualised sight test: they need extra time, multiple appointments, or perhaps the use of non-standard testing equipment. They need a clinician who is able to understand their needs and deliver a sight test that will not contain lots of jargon. The clinician also needs to be able to report back to the GP, so they have got it on record that the patient has had a sight test, what the results were, and whether they were referred or they just need an updated prescription and a new pair of spectacles.

The service was refreshed in 2020, and it now includes autistic people and people of all ages with a learning disability. There are somewhere around 9000 people with a learning disability and about 21,000 autistic people in South East London. It covers the whole spectrum.

What would you say to encourage practices to sign up to the pathway, and about the benefit of accessing that patient base?

Trang Dinh (TD): Trevor’s team and I have been working together, and it’s been a wonderful step forward. I’m a pharmacist by background and for the Integrated Care System (ICS) I cover South East London, leading in learning disability and autism. In my other job, I work in a GP practice, so I see both sides of the coin.

We’re doing lots of webinars for all our clinicians – nurses, GPs, pharmacists – so those working in GP practices are aware of the Easy Eye Care Pathway. Those with learning disabilities have an annual health check. It’s like an MOT for people with a learning disability. This is where we’re promoting the pathway, so that patients can access the service. If clinicians understand what it means and how it can help their patients, that’s where you'll find it is most effective and accessible.

Patients might not be aware of the pathway. They use their GPs as a point of access, for everything – both for their mental and physical health. If we get all our clinicians to understand the pathway and use it, it’s going to catch all these patients who might not necessarily be aware of the service thar is out there.

It’s not just GP practices we’re working with. We're working with lots of forums, and we cover all six South East London boroughs. Trevor’s team and I recently attended the Lewisham Autism Strategy Forum, to promote SeeAbility. This is just a small snippet of our work.

We have started small, because we need to streamline the processes and get our optometrists ready. So, there is a soft launch. In time, hopefully we will have optometrists offering the service all across South East London.

TH: I absolutely agree with that. The annual health check that the GP is able to do with people with learning disabilities is key to this. About 75% of people with learning disabilities have an annual health check. Of course, that is those that are registered with their GP and are on the learning disability register.

When they have an annual health check, if we can have it brought up that they need an annual sight test, and that that can be facilitated relatively easily through a referral programme to a single point of access – that's the key to getting these people involved. It has to be a smooth journey, whether it is from the GP, the borough learning disability team, or the hospital, into one of the accredited optical practices.

In the past, we’ve learned a lot from just giving out a leaflet to a patient or putting up posters in a GP’s practice. It doesn’t do enough to get these people involved, and it’s so important they’re involved. Lots of diagnostic overshadowing takes place with this group of patients. Often, their behaviour is attributed to their learning disability, whereas it could be attributed to the fact that they just need a pair of glasses so that they can see clearly.

We’ve got lots of case studies with people where that has happened. We’ve got case studies where people have been aggressive, but it was that they were short-sighted and couldn’t see, and that was the thing that caused their aggression.

Often, their behaviour is attributed to their learning disability, whereas it could be attributed to the fact that they just need a pair of glasses so that they can see clearly

 

It sounds like practitioners and communities working together rather than in silo is one of the most important parts of this process?

TH: Absolutely, I would agree. It’s a service. It’s a primary care pathway that needs to be promoted constantly. It’s not like other pathways that are out there, such as glaucoma or pre and post-cataract, which patients find themselves. If it’s not promoted, these patients will not get access to the sight tests that they need. The learning disability teams and the borough teams, and Trang and her colleagues, are working with us to constantly promote it to patient advocacy groups and GPs.

From the opposite perspective, how are you getting that message out to optometrists, and encouraging them to set up the pathway in their practices?

TH: I think South East London has more pathways into primary care practices than any other Integrated Care Board (ICB) region in London. This is the work of the Local Optical Committees (LOCs) in South East London and the lead provider organisation, Primary Ophthalmic Solutions, over the past 10 years.

If you take the Minor Eye Conditions Service (MECS) pathway, there are something like 40 practices in South East London that are signed up. If they’re signed up to MECS and they’ve done the training for delivering it, it’s not a huge step to do the WOPEC training for people with learning disabilities and get signed up on this pathway as well.

Many practices are seeing these patients anyway, it’s just that they haven’t been recognised for doing the work. We put out an expression of interest, and we had just over 20 practices who expressed an interest. There are 16 practices with a clinician who has done the WOPEC training and attended a CPD event about the induction to the programme, and are now accredited and currently offering the service.

We can talk to the clinician, and it’s important that they get accredited. But the practice team also needs to be aware of what’s going on. We’re proposing that we go around and talk to practice teams, and perhaps suggest that they have a learning disability champion within the team, who is the first port of call.

These patients will be phoning up and coming in. Not all contact will be through the single point of access. The team needs to be aware of how to address these patients when they come in: what to ask them, and what to say about the 'About me and my eyes' information form, which they need to fill in before the appointment. It’s about the team, because they’re the first port of call for patients when they walk through the door or pick up the telephone. It isn't the clinician.

Many practices are seeing these patients anyway, it’s just that they haven’t been recognised for doing the work

 

How can practices build a relationship with their ICB?

TD: The pathway is great, but it is only when we use it that it will become even greater. That’s why it’s important that we make those connections. We have some great pharmacies connecting already, and it’s important we have the same with optometrists. We are encouraging optometrists to reach out, and have that communication in place.

We want to make sure everything runs smoothly, whether patients are referred or whether they refer themselves. Trevor has worked on that side of things: making sure practices are clear on what’s happening, and making sure they are understanding the pathway, for when the patient finally gets there.

These patients are vulnerable; they might not be able to reach out like others can. When they get there, they need to be communicated with in the right way, with the appropriate reasonable adjustments provided, so that they can make the most of the service. So, we’re working closely with regards to communication, creating that relationship with the practices, but also making sure the referral pathway is as smooth as possible.

It’s both sides of the fence: making sure everyone knows what we’re doing, so that it runs smoothly. There are going to be teething issues at the beginning. But if you already have a great foundation and a great relationship, that’s going to be ironed out.

Because I sit in a GP practice, I see patients’ views. I’ll try to think like a patient, and work through that pathway to see what we can do better, and how else can we forge that relationship to make it a much better process.

These patients are vulnerable; they might not be able to reach out like others can. When they get there, they need to be communicated with in the right way, with the appropriate reasonable adjustments provided, so that they can make the most of the service

 

In terms of this pathway, are there any specific lessons that optometry could take from pharmacy?

TD: Historically, pharmacies have been very integrated with the ICB. If that ICB-optometry relationship can be developed locally, you’re going to see a much greater effect. The ICB understands things at a local level. It’s about looking at how we can work in a more integrated way , so all the clinicians and patients understand what optometry can do. That’s where you're going to get a really great service, better patient outcomes, and reduce health inequalities.

TH: Pharmacy now is being suggested, and quite rightly so, as the first point of call, as opposed to the GP. I think pharmacies and optical practices inevitably need to work together.

My experience has been in a large optometry practice, which has a pharmacy connected. Of course, with the local pharmacist in practice, we have a very good relationship. The patient attends the pharmacy, and the pharmacist says, ‘actually, it is a dry eye problem, go over to the optometrist and have a chat to them.’

I think we can do the same thing with people with learning disabilities. Hopefully, pharmacists will start asking patients when they last had an eye test, and speaking to the carer about making an appointment at one of the practices that has the pathway in place. It would be great if that could happen, because pharmacies are a key part of primary care. I think we should be working much more closely together.

TD: It might just mean crossing the road to your local pharmacy and saying, “I sit here and you sit here. Why don’t we work together?”

TH: I think that’s important. We’ve had difficulties in the past, trying to get secondary eye care and primary eye care working together. It has been, sometimes, a taboo for ophthalmologists to come and talk to optometrists. I’m glad to say that that seems to have been broken now. There are lots of meetings that optometrist attend, where ophthalmologists speak. It’s in the patients’ interests, and that’s what we are all there for.

If an optometry practice wants to focus at a local level, what would you say to break down that barrier they might feel with the ICB?

TH: There are two ways. One, attend LOC meetings. That is key to finding out how the LOC interacts with the ICB.

Two, talk to the lead provider. If services are being offered in their region, such as MECS, pre and post-cataracts, or glaucoma, and they’re not involved, they can speak to the lead provider (in the case of South East London, Primary Ophthalmic Solutions). They are the connection between the practice and the ICB. They’ll be very keen to discuss which pathways are available in that region, and how you can become part of those pathways.

We understand that practices are businesses and they, like any business, have to generate money and make a profit. But clinicians are very keen to help their patients in whatever way they can, and this is just another way of doing that and being recognised for it by NHS England.

TD: There are plenty of ICB contacts out there, but from a practice point of view it might be hard to reach out and know where to go first. In every ICB, there’s a primary care team. That primary care team can help you navigate to the right place for you, whether it’s the learning disability team or the medicine management team. If you want to work closely with pharmacies, there’s also a team for that. My advice would be to reach out, and go to a meeting or a forum. You’ll make connections there.

I’m so passionate about this exciting service. Trevor’s team has done such great work. I’m such an advocate; I’m yelling it from the rooftops. Every meeting I’m going to, I’m saying, ‘do you know about this?’

TH: Every day, I’m finding out new things about GP practices, such as that there are such people as social prescribers, which I didn’t know about. There are annual health check coordinators being put in post, certainly in South East London. These are other people who we need to be talking to and getting the message across to. It’s not just the GP. The GP is very busy, and in their annual health check, by the time they get to eye care, they’ll often have referred the patient for three other conditions. They’ll have almost started to run out of time. If we can talk to these other people, who are really important members of practice teams, that’s going to be a great help.

TD: I’m trying to encourage optometrists to go out there: speak to your GP practices, and tell everyone, whether it’s your pharmacy or your local forums, about what you’re doing. People aren’t aware, and people are going to be so surprised and so happy that the service is there.

Someone will know someone with a learning disability, or an autistic person. I think sometimes when we work in silos in our practice, we forget that there’s a world out there. It’s working hand-in-hand for patients, really. So, I would totally encourage that.

TH: We are in South East London, and the service operates in the North West of England too. That probably leaves us with another 35 or 38 ICBs to tackle. It has to be across the whole of England in the end, because otherwise, you’re in a postcode lottery. Someone who is in North Kent, just across the border from South East London, doesn’t have access, which is crazy. We talk about health inequalities, and that’s one of them.