Agenda an slides from the Opthalmology Specialty Workshop

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Ophthalmology
Workshop
Elective Care Transformation Programme
Specialty Based Transformation
30th October 2017

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Housekeeping

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Programme
12.00: Lunch and networking
12.30: Why are we here? Purpose of the day & overview of the Elective
Care Transformation Programme Specialty Based Transformation work
stream
13.00: Challenge framework discussions to capture ideas from the room and test
our thinking
• Current elective care challenges
• Key drivers
• Possible solutions and intended outcomes
• Patient profile and co-morbidities/considerations
• Inclusion of interventions in the ‘100 day challenge’ – challenges
and other opportunities
14.50: Next steps, roles and responsibilities
15.00: Close

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Intended Objectives and Outputs
• Increased understanding of the elective care rapid testing
work – in particular the 100-day challenge
• The importance of the clinical leadership role moving
forwards
• A challenge framework for Ophthalmology that includes:
• Current elective care challenges
• Key drivers
• Possible solutions and intended outcomes
• Patient profile and co-morbidities/considerations
• Inclusion of interventions in the ‘100 day challenge’ –
challenges and other opportunities
• Identification of the key priority intervention, with a
compelling case for change
• Next steps, roles and responsibilities

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Why are we here?
Elective Care
Transformation Programme
Ophthalmology Specialty Workshop
30th October 2017

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Elective Care Transformation:
Right Person, Right Place, First Time
Vision statement:
Our work will contribute to better health outcomes for patients needing
planned care by ensuring that only the people who need to be in
secondary care are referred there. We will work with clinicians to
develop guidelines and tools that support frontline health professionals
so more people see the right person in the right place, first time. This
will enable efficient use of resources – including through promotion of
self-care and early adoption of new technologies.

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Elective Care Transformation Programme
Three initial work streams supported by smaller projects
Specialty-based
transformation
• A national programme to test
radical changes to the referral
and outpatient process in a range
of high volume specialties.
• Based on testing, the national
team will develop the policy
framework, implementation
guides and continue to maintain
an evidence base for demand
management solutions.
• Regional teams will lead on the
implementation and spread of the
solutions across local systems.
High Impact Interventions
• The High Impact Interventions will
support delivery of patient centred
changes in managing demand.
They will concentrate on areas
where there are opportunities to
ensure that patients are treated in
the right place, by the right
person, first time.
• The initial high impact
interventions are MSK triage and
clinical peer review.
• Regional teams will work with
CCGs to embrace these
interventions in 2017/18.
Diversion of referrals
• A trial in Barking, Havering and
Redbridge which used ERS
capacity alerts to divert GP
referrals away from providers
where patients were unlikely to be
seen within 18 weeks has proved
successful.
• This will now be rolled out across
the country. Further testing will
also be carried out.
• Regions will be asked to intervene
where planned diversions are not
being achieved.

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Specialty Based Transformation Rapid Testing
Elective Care Development Collaborative: Rapid change led by the front line
Wave Specialities/pathways tested
Indicative
testing period
1 Gastroenterology and MSK & Orthopaedics Complete
2 Diabetes, Dermatology and Ophthalmology Dec – Mar 2018
3 Cardiology, ENT and Urology Jan – Apr 2018
4 General surgery, Respiratory and Gynaecology May – Aug 2018
5 General medicine, Neurology and Radiology Sept – Dec 2018

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Learning from wave 1
Collaboration and creating the
conditions for change and rapid
testing
Stakeholder engagement
Clarity around how
rapid testing
feeds into
expected
outputs
Importance of evaluation and
demonstrating impact

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Wave 1 Interventions and Case Studies

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Wave 1: Specialty Based Transformation Handbooks

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Benefits evident from Wave 1
Rethinking Referrals
• Increase access to care
• Reduce waiting times
• Reduce unnecessary or
inappropriate referrals
• Improve identification of
appropriate patients for
referral
• Reduce secondary care
follow ups
• Support patient
management in primary
care
• Enable effective
management in the
community
• Improve patient
experience
• Improve patient outcomes
Self-management support
and shared-decision
making
• Increase the quality and
amount of information
available to patients and
practitioners
• Improve communication
• Monitoring of health status
• Increased patient access
to digital self-management
material
• Increase patients’
understanding of their
condition
• Increase patients’ ability to
self-manage
Transforming Outpatients
• Improve access to care
• Offer telephone follow up
to patients without
complications
• Offer more flexible options
for follow up
• Improve data quality
• Support patient
management in primary
care
• Enable effective
management in the
community
• Improve patient
experience
• Improve patient outcomes

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The ripple effect – how we
influence the system
Health and
social care
system
ProgrammeWave
Site
team

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Operationalisation of the Elective Care
Specialty Handbooks
A developmental approach

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Timing of key events
Wave 2 = weekly specialty team meetings
= locally co-ordinated site level
= national peer events
W/C 09/04
Local Sustainability
Review
Oct Dec Jan FebNov Mar May
Structured local programme - Stockport
Structured local programme - Lincoln
Structured local programme - Norfolk
Structured local programme - Dorset
Design and mobilisation Challenge period – testing ideas Dissemination
Apr
31st Oct
Leadership
Collaborative
Launch
28-29th Nov
Coach training
4th Dec
Stockport
13th Dec
Lincoln
X-mas
shutdown
Team design
Data infrastructure
Support structures
9th, 10th + 12th Jan
Specialty cross site team
events
W/C 12/02
Local Mid-Point
Review
Leadership
engagement
W/C 29/01
Specialty webinars
W/C 19/02
Cross site Mid Point review
4-15th Dec
Local Launch events
14th Dec
Norfolk
TBC
Dorset
W/C 16/04
Cross site Sustainability Review
W/C 19/03
Specialty webinars
Work with each site to get
launch ready
Integrate agenda locally
Programme logistics
Easter

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Challenge
Framework
Development
Ophthalmology Specialty Workshop
31st October 2017

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Wave 2 Themes
The high level elective care pathway developed in wave one, will ground the programme in a
common understanding of the challenge, approach and goals across the collaborative
Advice & guidance
Triage
Standard referral form
Post referral feedback
Streamlined diagnostics
Self management education &
increased engagement in
decision making
Tools & technology, e.g.
patient decision aids/self
management tools
Increased access to non-
clinical support, e.g. vol sector
Virtual Clinics
Multidisciplinary outpatient
clinics
Alternatives to consultant led
follow ups
Patient led follow ups

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Emerging challenge framework
Exploring the potential areas for experimentation
Rethinking referrals
Advice and guidance
GP access to specialist
expertise to aid better
management of patients
and to reduce unnecessary
referrals
Triage
Triage of referrals in order to
inform peer review, ensure
patients see appropriate
secondary care clinician,
and/or re-direct patients to
different care settings.
Standard referral forms
Approved clinical referral
forms to improve
workforce mobility
Streamlined diagnostics
Rapid access to
diagnostics pre-referral
into secondary care, e.g.
within community settings
Post-referral feedback and GP education
Multi-disciplinary feedback on referrals, to provide feedback loops,
ensure standardisation of referrals & communication across care
settings. This would include improving patient access to out of
hospital services & community services, such as physio and
exercise classes to support self-management and alternatives to
secondary care referrals.
Access to training for high volume specialties to increase patient
management in primary care & inform referrals made.
Transforming Outpatients
Virtual clinics
Where appropriate,
outpatient appointments to
be completed virtually, such
as by phone or email.
Multidisciplinary outpatient
clinic
For relevant
conditions/specialties, joint
clinics available for patients to
access diagnostic services in
order to reduce the number of
outpatient appointments required
to determine treatment pathway.
Patient-led follow-up
Putting patients in the
driving seat of follow-up
appointments through the
use of patient monitoring
and management plans;
access to appointments
when needed through rapid
access clinics.
Alternatives to consultant led
follow ups
Where appropriate, follow-ups
to be completed by trained
professionals; freeing up
consultant time.
Shared Decision Making
Patient engagement in shared
decision making and self
management education.
Increase understanding of risks,
options and consequences to
support informed decisions about
treatment/referral
preferences/provider choice.
Tools & Technology
Patients are given access to
different tools, including
decision aids and self
management tech, to help
better manage their conditions.
Increased access to other help/support
services (eg vol sector)
Opportunities for non clinical services
(and peers) to support with patient
education and decision making.

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Wave 2 sites
RTT (period) GP referral
growth
(15/16-
16/17)
Total referral
growth
(15/16-16/17)
1st Outpatient
growth
(15/16-16/17)
Follow up
outpatient
growth
(15/16-16/17)
Patient
experience
measure?
Central Norfolk
Dorset
Lincolnshire
Stockport
Central Norfolk
Dorset
Lincolnshire
Stockport The CCG have identified a backlog of new consultant to consultant referrals. This is to be investigated ahead of the leadership event.

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High volume conditions
• Cataracts
• Age-related Macular Degeneration
• Glaucoma
• Diabetes-related eye disease

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Key challenges - Ophthalmology
The Royal College of Ophthalmologists suggest the following actions for
commissioners to alleviate the risks of delayed follow ups while work continues to
increase specialist capacity in primary and secondary care
• Identify the particular patient groups at risk who require ongoing follow up for chronic disease monitoring
and management and ensure agreement about safe new to follow up ratios for these specific conditions
• Have a clear understanding of the local issues and data around the extent and nature of the delays that affect follow
up appointments and actively monitor and report on these – this will help to drive change if managed appropriately
• Consider agreement on KPIs/Commissioning for Quality and Innovation(CQUINs) to limit the delays (eg limit delays to
be no more than a 25% time delay from the time determined by the clinician based on clinical judgement or disease
specific guidance, or target that 90% of patients should be seen within the clinically requested time scale)
• Explore incentives/KPIs/CQUINs to promote models of care within both primary and secondary which maximize
current capacity using nationally recommended pathways eg the development of virtual clinics, development of
protocols, connectivity
• Agree access and ‘Did Not Attend’ (DNA) policies between commissioners and providers that reflect clinical risk
(eg clear policies for the number of DNA and cancellations and thresholds for discharge. Enforce a requirement for the
records of all DNAs and cancellation patients to be reviewed by clinicians for risk based decision on outcome with clear
pathways for communicating these decisions to primary care clinicians). Resist ‘standard’ DNA letters
• Develop an active management plan of activity in Ophthalmology to work across the primary /secondary care
interface and between secondary care providers in the region, to identify suitable patients and networked
pathways for management in different secondary care and community locations and the training needs and
infrastructure to deliver this
• Commissioners should identify where the new tariffs do not adequately cover costs for safe chronic disease outpatient
care and consider local contract variation to decrease patient risk whilst ensuring incentives for effective and efficient
care

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Key challenges - Ophthalmology
• The Royal College of Ophthalmologists commissioned The Way Forward to identify current methods
of working and schemes devised by Ophthalmology departments in the UK to help meet the
increasing demand in ophthalmic services. The key recommendations were:
• Identify the best practice model for the delivery of ophthalmic services
• Develop a framework for expanded roles of ophthalmic nurse, technician and scientist
• Collect and report data and make it mandatory
• Maximise capacity to use resources effectively
• Empower/inform patients and promote personal responsibility
• The College has also published several service standards guides relevant to the Specialty Based
Transformation Workstream:
• Virtual Clinics for Glaucoma Care (2016)
• Primary Care Ophthalmology (2013)
• Ophthalmic Outpatient Department (2012)
• Sustainability in Ophthalmology (2013)

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Ophthalmology: size of the problem & role of
the specialty
2million with reduced vision, double by 2050
9 million treated annually in hospital eye services
400,000 cataract operations performed annually in NHS
>10% of over 65yrs have some form of visual impairment
Sight loss associated with trauma, psychiatric problem= care home dependent
The cost of blindness is £8bn per annum
Leading to:
Overwhelming hospital services & delayed treatment lead to losing sight
Supporting initiatives:
The Way Forward identify the best practice model for the delivery of ophth services.
Competency framework Develop FW for expanded roles of ophthalmic nurse, technician and scientist.
The Three Step Plan
1. Collect data/report and make it mandatory
2. Maximise capacity to use resources effectively
3/ Empower/inform patient: promote personal responsibility
Reducing risk and improving timely care for eye patients
RCOpth

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Ophthalmology Challenge
framework
System Challenges:
Multiple outpatient
appointments before the
patient gets the care they
need
Increasing GP
referrals
High ratio of rejected
referrals or discharge
from 1st Outpatients
Increasing long-term
conditions that require
continuing monitoring
and support
Multiple follow up
appointments
Patient pathways that
require multi-
disciplinary input
Workforce and
capacity pressures
Fragmented
commissioning of services
Increasing demand driven
by ageing population
Chronic eye-conditions require
continuing follow up appointments
to prevent sight-loss
Long waiting times with
significant quality risk from delays
Very high volume
specialty without the
capacity to meet rising
demand in secondary
care
Solution themes:
Rethinking Referrals Shared Decision Making and Self Management
Support
Transforming Outpatients
Possible interventions:
Advice & Guidance
Standardised referral templates
Referrals triage
Multi-disciplinary post-referral feedback
Streamlined diagnostics
GP communication training
Self-management education
Technology enabled self-management
Self-refer follow-ups
Telephone/virtual outpatients
Multi-disciplinary primary care/community teams
Nurse/AHP led follow up
Measurable impact:
Reduced
referrals/pop.
Reduced outpatient
activity/pop
Improved patient
experience
Patients feel more able to
manage their condition
Reduced median
waiting times
Improved RTT 18 week
performance
Increased clinical
satisfaction

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Possible interventions
• Saturday/evening clinics and new patient clinics –are these sustainable on top
of full-time schedule
• Process for identifying glaucoma patients who need follow up so no one gets
‘lost’
• IT infrastructure: EPR, PAS, (most effective with two-way talking between these
systems, to enable relevant clinical information to be fed in to PAS) medisoft, i-
reporter, Cerner, Eldene, meditech
• Virtual follow up for medical retina
• ‘In-house validator’ for patients on the 18-week RTT pathway to oversee where
patients are on the pathway and follow up any that are delayed. Human input
necessary – can be less efficient and still needs to be managed. Regular
meetingswith management and clinical team are essential to reduce risk.
• Risk stratification for patients using data on patients waiting for appointments
generated by PAS. Every patient coded before they can be booked for follow
up

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Key stakeholder groups for
Ophthalmology
• Royal College of Ophthalmologists
• Clinical Council for Eye Health Commissioning
• College of Optometrists
• RNIB (Royal National Institute of Blind People)
• Optical Confederation
• British and Irish Orthoptic Society
• Local Optical Council Support Unit (LOCSU)
• UK Vision Strategy
• Department of Health – Dental and Eye Care
• NHS England Primary Care Optometry commissioning
• NHS Improvement – Patient Safety and Quality

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Contact details
Email: england.electivecare@nhs.net