Ophthalmology

Improve conversion rates for patients referred for cataract surgery to 80-85% by implementing consistent referral criteria, improving training for community optometrists and using shared decision-making tools during the referral process. Ensure that patients who wish to discuss surgery with an ophthalmologist to make a final decision are able to do so. Actions: a) Commissioners and providers to agree consistent referral criteria and make conversion rates a key performance indicator (KPI) in contracts. b) Commissioners and providers to consider whether they need to develop any additional training for optometrists, based on audit of conversion rates. The audit should involve optometrists. c) GIRFT to support implementation of patient shared decision-making aids to be used by community optometrists and providers, along with a process for auditing their usage. Stakeholders to include RCOphth, CoOptom and patient groups, with input from NHSE and NICE as required. d) RCOphth and CoOptom to consider whether further support and guidance regarding referral criteria or training. e) Providers to report conversion rates in routine data collection for cataract and share data with referring optometrists. GIRFT to discuss enablers with NHSE.

Deliver routine cataract surgery in a maximum of 30 minutes of theatre time, through streamlining turnaround processes. This often requires staff to facilitate faster turnaround and does not apply to more complex cases. Actions: a) Providers to review the whole patient pathway for routine cataract surgery, from referral to post-operative care, engaging with relevant members of the whole team, with a view to optimising the process. This includes examining pre-assessment to identify suitable patients for high-volume surgery using risk stratification and patient information; admissions; in-theatre processes and post-operative care. b) Providers to train a consistent and dedicated specialist multidisciplinary theatre team to perform high-volume lists. c) Providers to develop high-volume lists (more than eight patients per list) for appropriate patients. d) RCOphth to incorporate high-volume lists into revised training curriculum, with all trainees to gain experience in performing high-volume lists and senior ophthalmic trainees to be trained to lead high-volume lists. e) NHS Improvement to measure baseline data for theatre efficiency. f) Providers to audit theatre utilisation against baseline data and, where they are not meeting the 30-minute theatre time, identify the root cause and take appropriate action.

Use commissioned primary care optometry services to review patients who have had uncomplicated / routine cataract surgery and have no serious ocular comorbidity. Actions: a) Providers and commissioners to work with optometrists to implement pathways so that at least 80% of uncomplicated cataract patients without ocular comorbidity e.g. glaucoma or diabetic retinopathy can receive follow-up and discharge via primary care optometrists, with payment dependent on receipt of post-op data. b) Baseline data on post-operative assessments, including whether patients were assessed in hospital or at a primary care optometrist, to be routinely collected. c) RCOphth and CoOptom to consider the need for further guidance and training for hospital teams and primary care optometrists. d) Providers, commissioners and primary care to agree clear governance and data sharing requirements, both from primary care to hospitals and vice versa, before any new pathway goes live. e) Providers, commissioners and primary care to ensure that post-operative visual acuity and refractive data is submitted to the NOD or other suitable data collection mechanism.

Reduce rate of false positive referrals for patients with glaucoma by instituting consistent referral criteria in line with 2017 NICE guideline and referral filtering schemes. Actions: a) Commissioners to commission referral filtering schemes in addition to GOS, as recommended in the 2017 NICE guidelines, in consultation and agreement with providers. Schemes to reflect NICE guidance and CCEHC frameworks. b) Commissioners to consider use of NHS Standard Contract mechanisms to implement criteria and audit adherence. c) NHSE consider developing a mechanism to enable referring optometrists to receive feedback on the results of their referrals. d) GIRFT to collect business cases and evaluations of referral filtering schemes to build evidence about the cost-effectiveness of implementing different approaches.

Adopt a model pathway for glaucoma drawing on NICE guidance, including risk stratification, MDT working, virtual clinics and active discharge policies for previous glaucoma suspects in whom the condition has been excluded. This core pathway should be supported by qualified medical and non-medical ophthalmology HCPs and community pathways. Actions: a) Commissioners and providers to consider model glaucoma pathways (including community pathways) as in The Way Forward and the CCEHC SAFE Glaucoma Service System, and adjust processes accordingly to enable more patients to be seen in the right place at the right time. b) Providers to introduce consistent risk stratification for all glaucoma patients. c) Providers to adopt MDT working in glaucoma diagnosis and management, addressing workforce training as required to build capacity in the wider team. d) Providers to introduce virtual clinics for glaucoma. e) Providers to develop discharge policies and processes in line with existing NICE guideline (2017). f) Providers to educate staff about the discharge policies to underpin consistent application. g) Consultants and senior clinicians to oversee the implementation and application of discharge policies.

Implement the actions of the High Impact Intervention (HII) on failsafe prioritisation for all ophthalmology patients, particularly those with glaucoma and medical retina conditions, and on undertaking a risk audit to identify and discharge those patients that are clinically ready to be discharged. Actions: a) Providers to audit their approach against the recommendations of the High Impact Intervention and develop their processes accordingly. b) Trusts to calculate the whole-time equivalent (WTE) need for the failsafe officer role as part of their annual business planning. c) Providers to implement the approach recommended in the High Impact Intervention and undertake a risk audit at least annually. This should be a joint responsibility for clinicians and managers. d) Commissioners to work with providers, based on the outcomes of the annual risk audit, to assess the need for additional capacity within the hospital eye service (including virtual clinics) and primary care optometry.

Develop a national standardised referral pathway for suspected diabetic maculopathy that includes the use of OCT as a form of referral refinement to reduce unnecessary referrals from screening services. Actions: a) GIRFT to work with NHSE and the screening programme provider to develop the national standardised referral pathway. b) Providers and commissioners to manage referrals in line with the pathway and any accompanying guidance.

Increase the capacity and productivity of wet AMD pathways, through more extensive use of virtual clinics for stable patient monitoring and clean rooms for intravitreal injections, while training more members of the non-medical HCP team to carry out injections. Actions: a) Providers to review their wet AMD pathways to identify opportunities to use virtual clinics to reduce the number of face-to-face outpatient appointments. The CCEHC frameworks, including SAFE-AMD, may be of use in this review. b) Providers to consider business case to add clean rooms to minimise theatre usage and use trained non-consultant staff to conduct a greater proportion of injections. c) GIRFT, working with NHS Improvement, to develop/collect business cases to demonstrate cost benefits of clean rooms and training more staff to conduct injections. d) GIRFT to work with RCOphth, CoOptom, BIOS and RCN to consider whether there are any additional training needs.

Continue to engage with stakeholders in order to facilitate the use of available treatments for the management of all wet AMD patient groups as well as the use of new treatments as they are developed.

Review the delivery of the national 4-5 year old children's vision screening programme and consider the possibility of making it mandatory to help reduce unwarranted variation in implementation around the country. Actions: a) GIRFT and PHE to review the delivery of the national 4-5 year old children's vision screening programme, examining issues including: the quality of this screening service where it is available; who carries out the screening, audit etc; uptake of screening; outcomes; and costs, both to the local authorities who commission it, and the resultant upstream NHS cost of managing referrals from screening. b) Based on the review outcomes, GIRFT and PHE to consider the possibility of making vision screening mandatory to help reduce unwarranted variation in implementation around the country. c) Providers, supported by BIOS and British and Irish Paediatric Ophthalmology and Strabismus Association (BIPOSA), to review pathways used post paediatric strabismus surgery to understand the approaches taken and assess whether there are opportunities to increase consistency or make better use of community provision. d) GIRFT to examine audit results with NHSE CRG to assess whether there is any unwarranted variation.

Develop a clear pathway for out-of-hours emergency eye care, implemented locally and regionally and agreed among all providers, supported by contractual arrangements and SLAs. Actions: a) Commissioners and providers to agree pathways to deliver this, drawing on best practice outlined in RCOphth OSG, SAFE and other CCEHC frameworks. b) Commissioners and providers to ensure that agreed pathways are reflected in clinical agreements and financial SLAs for all out-of-hours services in their area.

Review delivery of specialised services to ensure all aspects of the service specification, including data collection, are being met. Actions: a) Providers and NHS Specialised Commissioning to improve their processes for recording data around specialised services, in particular around procedure numbers and outcomes. b) Regional specialised commissioning teams to review the commissioning of specialised services in their region, and in particular to focus on moving to a hub and spoke model. c) NHS England and NHS Specialised Commissioning to use the data collected by GIRFT to inform the forthcoming review of the service specification and development of the dashboard for specialised services in ophthalmology.

Implement specialised ophthalmic MDTs across all units. Actions: a) Providers to establish specialised ophthalmic theatre teams. b) GIRFT to work with Health Education England (HEE), RCOphth, CoOptom, BIOS, RCN and AHPO to develop consistent national frameworks for specialist roles in ophthalmology.

Implement the structured training curriculum which has been developed for non-medical ophthalmology health care professionals (HCPs) based on the Ophthalmology Common Clinical Competency Framework (OCCCF). Actions: a) GIRFT to work with HEE, RCOphth, CoOptom, BIOS, RCN and AHPO to ensure that training arrangements reflect OCCCF. b) Training providers to implement agreed programme locally. c) Providers to put in place training strategies with clear timelines for non-medical staff.

Undertake a detailed assessment of patient pathways to identify needs for more space to offer patient-centred care in different settings. Actions: a) Providers and commissioners to assess pathways and identify any areas where space may be a constraint on their overall capacity or their ability to deliver patient-centred care. b) GIRFT to work with NHS Improvement to examine options and gather case studies for increasing space, which may be in a community setting and include virtual service delivery. c) Providers to determine if space is a constraint on delivery of ophthalmology pathways locally and, with commissioners, consider options to provide increased space or rethink care settings.

Consider changes to pricing arrangements that better reflect costs associated with different case mix and types of activity. Actions: a) GIRFT to commission costing and pricing analysis to investigate the payment system's effect on providers with differing case mix and types of activity, involving stakeholders below. b) Discuss results with NHS England/NHS Improvement, relevant professional bodies and other stakeholders, including the United Kingdom Opthalmology Alliance and Independent Hospital Providers Network to agree next steps.

Improve arrangements for training, taking into account the different skill mix of different providers. Actions: a) GIRFT to work with HEE to support commissioners in assessing the impact of commissioning decisions on training and providing suitable arrangements for trainees.

Improve clinical governance and information sharing arrangements in relation to services provided by independent sector providers. Actions: a) GIRFT to provide advice on clinical governance and information sharing as part of its work with the independent sector, cognisant of work already underway in this area. All providers should also discuss and resolve governance issues locally.

Facilitate joint working within providers, between providers and with primary care to continue the rollout of networked EPR in ophthalmology. Actions: a) Trusts to consider using the RCOphth Electronic Medical Records Standards to inform any EPR procurement exercise and make capability for information sharing a key criterion. b) Providers to explore feasibility of using existing EPR systems to support joint working and information sharing.

Improve the quality, depth and accuracy of data collected nationally about ophthalmology services and clinical outcomes, without adding to provider workloads. Actions: a) Providers, including independent sector providers, to increase case ascertainment for cataract surgery in the NOD to at least 85% of cases. b) GIRFT to work with RCOphth and NHS England to consider the introduction of, and develop requirements for, a national audit for glaucoma interventions (laser and surgery), based on the feasibility study undertaken by HQIP, including measuring clinical outcomes. c) GIRFT to work with NHSE to consider the introduction of, and commission a pilot for, a national AMD audit based on the feasibility study undertaken by HQIP. d) Trusts to submit data to all these national data collections as required. e) GIRFT to explore with NHS England, HQIP, the RCOphth and others the sustainability of national outcomes collections to maximise data sharing and reduce duplication in collections.

Enable improved procurement of equipment and devices through: cost and pricing transparency; aggregation and consolidation; the spreading of best practice; encouraging trusts to purchase all of their lenses through NHS Supply Chain; and reducing the unwarranted variation in procedure and instrument packs across the NHS. Actions: a) GIRFT to work closely with sources of procurement data such as PPIB and PLICS and use relevant clinical data to identify optimum value for money procurement choices, considering both outcomes and cost/price. b) GIRFT to identify short and long-term opportunities for improved value for money, including the development of benchmarks and specifications, and locate sources of best practice and procurement excellence, identifying factors that lead to the most favourable procurement outcomes. c) GIRFT to work with the UKOA and the new Category Towers to rationalise and standardise procedure and instrument packs across the NHS to reduce variation. d) Trusts and STPs to work with GIRFT and the new Category Towers, to benchmark and evaluate their products and seek to rationalise and aggregate demand with other trusts to secure lower prices and supply chain costs. e) GIRFT, UKOA and Category Towers to develop standard specifications for procedure packs to enable cost comparison, building on the work already commenced by UKOA. f) GIRFT to work with RCOphth, the NOD and the UKOA to develop and collect outcome measures to better inform procurement of intraocular lenses. g) GIRFT to establish an ophthalmology National Clinical Technology Advisory Panel (NCTAP) to review national specifications, device safety and efficacy as well as provide guidance on best value.

Reduce litigation costs by application of the GIRFT Programme's five-point plan. Actions: a) Clinicians and trust management to assess their benchmarked position compared to the national average when reviewing the estimated litigation cost per activity. Trusts will have received an updated version of this for ophthalmology in the GIRFT 'Litigation in surgical specialties data pack'. b) Clinicians and trust management to discuss with the legal department or claims handler the claims submitted to NHS Resolution included in the data set to confirm correct coding to that department. Inform NHS Resolution of any claims which are not coded correctly to the appropriate specialty via CNST.Helpline@resolution.nhs.uk c) Once claims have been verified clinicians and trust management to further review claims in detail including expert witness statements, panel firm reports and counsel advice as well as medical records to determine where patient care or documentation could be improved. If the legal department or claims handler needs additional assistance with this, each trusts panel firm should be able to provide support. d) Claims should be triangulated with learning themes from complaints, inquests, SUIs and SIs; where a claim has not already been reviewed as a SI/SUI, this should be carried out to ensure no opportunity for learning is missed. e) Where trusts are outside the top quartile of trusts for litigation costs per activity GIRFT we will be asking national clinical leads and regional hub directors to follow up and support trusts in the steps taken to learn from claims. They will also be able to share with trusts examples of good practice where it would be of benefit.