NatPaCT works with Primary & Care Trusts to help them learn & grow together , as connected and competent

2. NatPaCT works with Primary & Care Trusts to help them learn & grow together, as connectedand competent organisations and leaders of radical change to improve health & services for patients.

3. Chronic Eye Disease Management in Community Settings: First Report of the Eye Care Services Steering Group

4. Bob Ricketts Head of Access Policy Development & Capacity Planning Department of Health

5. Blindness: Vision 2020 - The Global • Initiative for the Elimination of Avoidable • Blindness • disease prevention and control • training of personnel • strengthening of the existing eye care infrastructure • use of appropriate and affordable technology • mobilisation of resources

6. NHS PLAN Core Principles 3,4,8 • The NHS will shape its services around the needs and preferences of individual patients, their families and their carers • The NHS will respond to different needs of different populations • The NHS will work together with others to ensure a seamless service for patients

7. “Fair for all and personal to you” John Reid 16 July 2003

8. Eye Care Services Steering Group • Set up by Ministers in December 2002 • Worked on GMS, dentistry and pharmacy and ophthalmics now moving forward • Growing need for eyecare services and major quality of life issues

9. Source ONS Source ONS Source ONS

10. Half of over 65s have impaired vision in one or both eyes • Increase in elderly

11. Four Pathways • Cataract • Glaucoma • Age Related Macular Degeneration (ARMD) • Low Vision Services • Diabetic retinopathy being tackled separately as part of Diabetes NSF

12. Design Principles • Make best use of available resources • Have fewer steps for the user • Make more effective use of professional resource • Show a high standard of clinical care with good outcomes • Improve access and deliver greater patient choice • Evidence based

13. Conclusions • Primary care ophthalmic services need to be developed to meet demographic demand • Partnerships with primary & secondary care, patients and carers essential • Integrated IT needed but not prerequisite • Voluntary agency and social services involvement important

14. Care Pathways Designed to Achieve: • Integrated eye care services • Better use of skills in primary care • Increased amount of care for all in accessible primary care settings • Increased role for professional groups in primary care

15. Recommendations • Cataract pathway to be implemented when waiting times reduced to 3 months • £73million additional funding to achieve 3 month cataract waits by December 2004 • Glaucoma pathway to be piloted initially • ARMD and Low Vision to be taken forward within existing funds • £4million for innovative projects and pilots • GOS Regulations to be amended to allow direct referral by optometrists

16. Why are we here? • Share our report with you • Consider, if you agree with us, how we take it forward together

18. Elizabeth Frost Director Association of Optometrists & Chair, Cataract Working Group

20. Background • Mainly elderly population • Many misconceptions about cataract surgery • Changes in HES • Action on Cataracts

21. Current Cataract Pathway • Patient reports sight problem to GP • Patient goes to optometrist/OMP for sight test and optometrist/OMP refers patient to GP • Patient goes to GP, referred to HES • Patient seen at HES, cataract confirmed, decision to operate, and put on waiting list • Patient attends HES for pre-op assessment • Patient attends HES for day case surgery • Patient attends HES for 24 hr check • Patient attends HES for 6 week check, 2nd eye discussed • Patient attends optometrist/OMP for sight test and new specs.

22. Proposed Cataract Pathway • Patient attends optometrist/OMP for sight test, cataract diagnosed and discussed, general risks & benefits of surgery explained, current medication listed, patient information given, and appointment made for HES, with choice of provider (copy of referral to GP for info) • Patient attends HES to see ophthalmologist and for pre-op assessment • Patient attends HES for day case surgery • Patient attends HES/optometrist/OMP for 24/48 hr check OR is phoned by cataract nurse to check progress (agreed locally) • Patient attends optometrist/OMP for final check and sight test, 2nd eye discussed.

23. Proposed Cataract Pathway Start Finish • 1. Patient attends optometrist • Sight test, cataract diagnosed and discussed • General risks and benefits of surgery discussed • Patient wishes to proceed, information given etc • Patient offered choice of hospital and appointment agreed • 4. Patient attends HES • or Optometrist • Final check • Sight test • Discharged or • 2nd eye discussed and • appointment arranged • 2. Patient attends HES • Outpatient appointment with • ophthalmologist* • pre-assessment (with nurse?) • Date for surgery arranged/agreed • (* details of medication etc • received from optometrist, GP or • patient as per local protocols ) • 3. Patient attends HES • Day case surgery undertaken

24. Who should be referred? • Not a ‘fast track’ service • Suitable for those who – • have a cataract that is interfering with their daily living • have been given basic information about cataract surgery, and risks / benefits • want to have surgery

25. Evidence of Success • Several services developed and audited • 90%+ referrals proceeding to surgery • cf 80% for traditional referrals • Reduced time to surgery from 12 to 3 months • Surgical outcomes meet RCO guidelines • Reduced DNA rates • Greater nurse involvement • High patient satisfaction

26. Constraints to Success • Not funded centrally through GOS budget • To be funded by existing PCT budgets • Investment needed in equipment and staffing • Needs mutual inter-professional trust and teamwork • Lack of IT booking links will hamper

27. Key Recommendations for local action • Reduce number of steps in pathway • Eliminate duplication • Improve IT links – optometrist/OMP/HES • Develop protocols for discharge from HES to optometrist/OMP with audit feedback • Agree funding

29. Stephen Vernon Royal College of Ophthalmologists & Chair, Glaucoma Working Group

30. Chronic Glaucoma gives tunnel vision 10 years

32. Testing for glaucoma

33. UK population by age - 2001 Age range

34. BMES PREVALENCE OF POAG <60 60-69 70-79 >80 Age Group

35. Estimated numbers of glaucomas in UK by age (1000s) Age

36. Current Glaucoma Pathway(Hospital Based Care) • Single screening opportunity by community optometrists with no standardised protocols • Diagnosis and continued care for life of all glaucoma (and many suspects) within Hospital Eye Service by ophthalmologists

37. Proposed Pathway (Community Based Care) • Community optometrists work to nationally agreed screening protocols which permit refinement of tests prior to referral • Glaucoma suspects and stable glaucoma patients managed in the community by COs and OMPs with interaction of community and HES teams where appropriate

38. The 5 Care Pathways Care Pathway 1 Ocular Hypertension Care Pathway 2 Glaucoma without other eye disease Care Pathway 3 Glaucoma suspect on discs and/or fields Care Pathway 4 Glaucoma in presence of other significant eye disease Care Pathway 5 Refinement of community optometric referrals

39. Proposed Glaucoma Pathway Start • 1. Patient attends community optometrist (CO) • Sight test, IOP over 21 (applanation tonometry) and/or visual field defect and/or excavated discs • Patient/optometrist makes appointment with optometrist with special interest in glaucoma (OSI) or OMP • 4. OSI/OMP manages patient in community setting • Regular reviews set in place • OSI/OMP relay data to hospital if significant progression for HES review if needed • 2. Patient attends OSI or OMP • Full history and assessment carried out according to protocol • Decision taken as to whether patient has ocular hypertension (OSI/OMP reviews) or can be discharged (return to CO) or has glaucoma (treat or refer to HES) • Patient advised, given information etc and further appropriate appointments made if needed • 3. OSI/OMP relays data to HES • HES reviews data, advises OSI/OMP regarding management and sets up review at HES if needed

40. Evidence Base • Only 33% of suspect glaucoma referrals found to have glaucoma by HES • Optometrists with additional training can assist in glaucoma management freeing up ophthalmologist and hospital time • Refinement of referrals for suspect glaucoma by specially trained optometrists reduces HES referrals

41. Constraints to Achievement • Funding issues - increased revenue costs • Training requirements • Legal issues for prescribing rights • Information Technology issues • Communication • Record keeping • Audit

42. Key Recommendations for Local Action • Community optometrists conform to College guidelines for referral of glaucoma suspects • HES services utilise optometrists to assist in glaucoma care within the HES • Community refinement of optometric referrals established utilising OMPs and optometrists with a special interest in glaucoma • Community care of “straightforward” glaucoma cases by OMPs and optometrists with a special interest in glaucoma

44. Frank Munro President College of Optometrists & Chair, ARMD Working Group

45. OBJECTIVES • Map out the current care pathway • Identify inhibitors & barriers to change • Identify areas for improvement • Develop proposals for a new integrated care pathway for patients with ARMD

46. WHAT IS AGE RELATED MACULAR DEGENERATION(ARMD)? • Acquired condition - > over 60 years • ‘Wet’ & ‘Dry’ forms • Affects central vision • Almost 1 million in England • Commonest cause of irremediable visual loss • Accounts for 14% blind & partially sighted registrations( 50% for those > 65yrs) • Limited credible treatment options

47. ASSOCIATION BETWEEN VISUAL IMPAIRMENT &….. • Increased mortality • Increased morbidity / falls / fractures • Increased road accidents • Increased anxiety & depression • Poorer self care & independence • Greater need for community & institutional resources • Social isolation - quality of life • Loss of income

48. DEMOGRAPHICS • By 2020 • A 25% increase in the over 65 population is expected • Incidence of ARMD expected to rise by 31% • AMD • 1998 approximately 8.3 • on people over the age of 65 in England and Wales • 4.3 million have impaired vision • AMD is the leading cause in over 65s

49. AMD: A Growing Problem • Burden recognised by government • NSF for Older People • Vision impairment is an intrinsic risk factor for falls • NICE: Recent guidance on PDT for wet-AMD • NICE to review new treatments in 2005 • In meeting future demand, service will have to respond to increasing patient numbers and delivering new therapies

50. Current Services • There are many good points about today’s services: • Access to angiography in most (if not all) eye departments • Access to Argon laser in all eye departments • Great awareness of AMD in general optical services • Prompt access for suspected wet AMD in most secondary care sites • In some centres access to LVA, LV1, social services advice is almost one stop