01.10.12
A new vision for eyecare referral
Source: National Health Executive Sept/Oct 2012
NHE hears about a new eyecare referral management system being used by NHS Suffolk to drastically cut referrals, save money, reduce waiting times and let more patients be treated by their optician rather than as a hospital outpatient. We speak to Nerinda Evans, head of commissioning and development at NHS Suffolk, and Chris Wilbraham, the former chairman of the Local Optical Committee, who helped get the service off the ground.
Referral gateways have come in for their share of criticism, especially systems that are so big they try to catch everything.
But in Suffolk, a referral management system in the eyecare pathway is proving a success with just about everyone – primarily because the clinicians themselves have helped implement it, rather than it just being commissioners telling GPs and opticians what to do.
Pressures in the system
Nerinda Evans, head of commissioning and development at NHS Suffolk, explained the background and why they decided referral management was necessary: “We were aware that we had nearly 24,000 ophthalmology referrals going to both of our acute hospitals, and of the pressures within our ophthalmology departments. There were long delays for outpatients, overcrowded outpatient clinics, people having to go back for more than one appointment, purely because of capacity issues.
“There was also a change in the national guidance from NICE with regards to patients with glaucoma and the scoring changed, which meant there was a large influx of patients into the hospitals who they then had to cope with quite quickly.”
In late 2010, NHS Suffolk undertook a review and interviewed clinicians and patients to get to the bottom of the issues. Evans said: “It rapidly became clear that we needed to look at some of the pathways, but also we needed to simply ‘turn the tap off’: in doing that, we discussed that with our local optometrists to get their views on what some of the issues were.”
Chris Wilbraham, who runs the triage service in Suffolk, is a former chairman of the LOC (local optical committee). He told us: “Some optometrists are a bit ‘defensive’ in their referral patterns, in that they will refer something that if they thought about more or did a few extra tests perhaps wouldn’t have referred. The patient then has potentially a two-month wait worrying about the situation, then possibly has to travel quite a long way to be told that actually there’s nothing wrong.”
He said a specific issue with eyecare referral is with glaucoma and non-contact tonometers, which are quick and easy to use and don’t need drops to be put in the patients’ eye. But historically, they’ve had a reputation for giving high readings, he said, and NICE guidelines stipulate that patients with pressure over a certain number need to be referred.
QIPP savings
Evans said: “To put it in strategic context, obviously as a PCT, with QIPP we had an amount to save in planned care. We could see that an awful lot of money was going into ophthalmology for first and follow-up outpatient referrals.”
Following the review of the problems, Evans said: “We deemed that triage to our optometrists was probably the best idea, and on the back of that we set up some local community services, the OpSI (optometrists with a special interest) services.”
The PCT then worked with local optometrists to set up Suffolk Primary Eyecare Ltd that does the triaging under the new referral gateway system, which uses a system called evolutio, run by healthcare entrepreneur Peter Price-Taylor, who has a degree in optical management. Evans said NHS Suffolk had previously experimented with smaller referral gateways in its orthopaedic and dermatology pathways, but neither was particularly successful, as they lacked the capacity to really “push back” on referrals.
Acute difficulties
The new system was implemented in July 2011. Evans said: “We had to do lots of negotiation with the acute trusts to get them to send referrals back so that nothing was sneaking through the back door – to capture everything going through the triage service. There were issues with some of the consultants at the hospital, who were obviously conscious it might have a personal impact, if the levels of demand went down.”
Wilbraham added: “One of the acute trusts was frankly struggling to keep up with what they had and I think they are quite grateful for the reduction. The other department is much more efficiently run.
“It’s a new service, with patients who would have been going to hospital now going to an optometrist, and the system relies upon the correct patients being picked out to be sent. Getting that right was one of concerns – a clinical concern.”
There are always suspicions about the relative importance of financial considerations in the clinicians’ and acutes’ thinking, Wilbraham said, but added: “These professionals do care about their patients; having said that, they have been watching us like a hawk for a year. Nothing’s come to light that I’m aware of – we can be confident in what we’re doing. There are no apparent clinical issues and the longer things go on, the better things look really.”
Behaviour change
Evans told us about another beneficial fall-out from the implementation: “We became much more aware of the referral practices of certain optometrists: it stopped them being quite so risk-averse.
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