Community diagnostic hubs and connectivity
Why we believe that optometry practices with effective IT connectivity are best placed to provide primary eye care including imaging and repeat measures in the community, and that community diagnostic hubs should focus on other clinical areas of need
In October 2020, the Richards Review led by Professor Sir Mike Richards was publishedi. The report, which was originally commissioned by NHS England prior to the COVID-19 pandemic, was asked to consider the case for radical change in the provision of diagnostic services. This scale of the review and its urgency was further amplified by the far-reaching impact of the pandemic in 2020.
In his foreword, Richards concludes: “To deliver the increase in diagnostic activity required now and over the coming years, and to provide safe, patient-centred pathways for diagnostics, new service models are needed.”
The initial scope of the review was to consider the large diagnostic requirements of secondary care such as CT and MRI scanning, but the remit widened to include other specialities with high volumes of patients, including ophthalmology.
Within the report, several recommendations were made with regards to new ways of working, including but not limited to:
- New pathways
- Community diagnostic hubs (CDHs)
- An expanded imaging workforce
- Improved connectivity and digitisation
With regard to ophthalmology, Richards noted several observations:
- Ophthalmology is one of the busiest specialties
- Many patients are missing their optimal recall date due to the backlog and delays
- A high proportion of patients can have clinical decisions made based upon data and image capture
- The role optometrists play is important in the initial identification of disease
- There are poor levels of connectivity between optometry and secondary care
In the review, Richards writes that CDHs can help to solve the challenges of volume and delay within ophthalmology. It is known that large, inner city, ophthalmology teams such as Moorfieldsii are keen to advocate this version of the future as it works well with their patient demographic.
What are we calling for?
We fully support the Richard review’s conclusion that optometry practices “provide a very valuable role” in delivery eye care, including the detection of eye conditions and disease “using digital imaging and OCT services, and collecting other key clinical information such as eye pressures.” We also support the conclusion that optometry practices “are currently poorly linked to NHS ophthalmology services.”
However, it is our view that the introduction of the CDH model into eyecare is both unnecessary and financially unwise. Optometry practices already have the clinical expertise and diagnostic infrastructure to deliver high quality eye care to patients, including digital imaging. These practices should be the first port of call without the need to use a CDH model.
There are four principles that support our position:
1. Diagnostic equipment is available at volume in optometry practices
The original premise of the review of diagnostic capability was to address the large, expensive, high usage volume pieces of diagnostic equipment that are needed and utilised by many specialities. Based on increasing demand and patient convenience, the review concludes that it is highly likely that all CDHs will provide the following:
- Imaging: CT, MRI, ultrasound, plain X-ray
- Cardiorespiratory: echocardiography, ECG and rhythm monitoring, spirometry and some lung function tests, support for sleep studies, blood pressure monitoring, oximetry, blood gas analysis
- Pathology: phlebotomy
- Consulting and reporting rooms
The diagnostic equipment commonly utilised in ophthalmology, such as visual field screeners, and OCT are far smaller, less expensive, and most importantly, are near ubiquitous in optometry practices. This provides two distinct advantages: throughput volume and availability, alongside the capital expenditure saving. It is estimated that within optometry practices there are at least 3,000 OCT scanners and around 6,000 practices. Even if 100 new diagnostic hubs were built, equipped with three OCTs per hub, it is our view that a CDH could not feasibly replicate the availability and accessibility of OCT within optometric practices.
2. Patient access needs are met by community optometry practices
Access for patients to healthcare generally is a key challenge. A report by Age UK titled Painful Journeysiv explored the challenges faced by patients in attending hospital appointments. This report identified three key issues, complete with sub issues:
- Long and uncomfortable public transport journeys
a. Cuts to bus services
b. Poor bus accessibility
c. Bus pass restrictions
d. Companion travel on public transport
e. Lack of awareness of public transport options
f. Underfunding of community transport options
- Hospital provided patient transport
g. Tightening of eligibility
h. Long waiting times for collection and return
i. Companion travel – hospital transport
- The cost to older people and their families
j. Long journeys for specialist treatment
k. Older drivers and the problems with driving to hospital
l. Hospital parking
m. Reliance on family and friends
n. High cost of private-hire taxis
We agree that some of these challenges may be improved by CDHs. However, the majority will not. CDHs are still examples of large footprint, centralised provision, often located near existing hospitals. In contrast, the 6,000 optometry practices in the UK are in familiar, accessible locations. They are accustomed to providing a patient-centric experience, and reduce or eliminate many of the issues identified by Age UK.
3. Capital expenditure outlay for CDHs to deliver eye care is a poor financial investment
We point to the example of OCT availability within optometry practice across the UK. Taking a conservative estimate of a cost of around £30,000 per OCT machine, our calculation is that the cost to the NHS to replicate this existing volume of OCT scanners would require capital expenditure of around £90m. To fully equip CDHs, that figure would need to include slit lamp biomicroscopes, visual field screeners, tonometers and other general examination equipment found in optometric practices. It is likely that this would at least triple the capital expenditure outlay, and represents poor value for money for the taxpayer.
This example is in contrast to a full-body MRI scanner, which can cost over £500k and requires significant additional investment to provide and maintain a suitable environment for its use. The equipment occupies large amounts of space and locating it in another location from the main hospital setting releases capacity and space within the hospital estate.
4. CDHs should not be the workaround for the need to improve basic IT connectivity for optometry practices
In his review of ophthalmology, Richards is critical of the lack of effective IT connectivity. We agree, and note it is a position the optical sector has long advocated.
Richards adds: “If IT links and consistency of equipment and training were better, many of these patients could be assessed by ophthalmologists through virtual clinics, based on data collected by optometrists. Some optometrists could also be upskilled or their existing skills better utilised to make decisions under hospital guidance and governance”.
We challenge this assessment. In our view, the existing skills of all, not “some”, optometrists are currently underutilised. Further, what is holding optometrists back is ineffective IT connectivity. It is the lack of IT connectivity that has meant that optometrists have been left with no choice but to make referrals because the details of previous hospital appointments are not available. Improved connectivity would mean every optometry practice can provide increased access for patients. This will help to reduce, and in some cases eliminate, the need for patients to travel significant distances. It will also release capacity in secondary care, enabling the approximately 1.9 million retinal imaging proceduresv to be conducted in primary care with the results transmitted digitally to the hospital for evaluation.
We propose that the solution must ensure all practices conducting sight tests have a safe, simple and secure option to communicate with secondary care colleagues. This can be facilitated by ensuring that all practices and all practitioners including locums have access to NHS mail addresses.
Currently, restricted funding means that there isn’t an easy mechanism for larger practice groups to obtain NHS mail and locums are reliant on benevolent practices to obtain access. By urgently fixing these issues to allow access to this established infrastructure, the requirement in the NHS planning guidance for direct referral from September 2023vi will be more easily met.
We are aware that there are currently multiple emerging solutions to address the more complex image sharing challenges in market. Some of these options are more established and feature-rich than others. To improve collaborative care and to find new ways of working between primary and secondary care, we advocate the following principles:
- The solution must form part of the contract for services and its costs must be included
- There must be an API to ensure there is no double keying of information. Double keying introduces the risk of errors and also introduces inefficiencies
- All providers must be visible on the system to optimise patient care
- Wherever possible, imaging is delivered in a primary care setting