GGC Provision of Shared Care Glaucoma

Situation:

• Government funding is available for Ophthalmology to address the large Covid-related backlog of long-term patients with sight-threatening conditions.
• The Government intention is for hospital patients to be seen by community optometrists on a fee per patient basis.
• Glaucoma patients have been identified as a priority group, within which some cohorts of the hospital caseload are suitable for protocol-based interim review by community optometrists.
• It is proposed to arrange for 1,000 glaucoma patients to be reviewed in the community by the end of March 2021, at a cost of around £78,000
• The proposed scheme has been jointly developed by the Ophthalmology Department, Community Optometry and the Primary Care Support Department

Background:

Glaucoma Trends, Guidelines & Initiatives

Glaucoma is a sight-threatening disease affecting a growing proportion of the population, traditionally managed by specialists within hospital eye services. Due to growing prevalence, the hospital caseload has been becoming unsustainable, with the potential for community optometrists to manage a portion of patients being actively explored.

This has been promoted by SIGN 144 – Glaucoma Referral and Safe Discharge from 2015 and by the Royal College of Ophthalmologists in its 2017 publication The Way Forward: Glaucoma – options to help meet demand for the current and future care of patients with eye disease.

This year has seen the launch of the NES Glaucoma Accreditation Training scheme (NESGAT), for accreditation of community optometrists to manage glaucoma, but roll-out has been disrupted by Covid.

Covid Disruption and Backlog

The Covid contingency has caused major disruption to the hospital-based glaucoma service, with around 6000 patients having had their appointments delayed or cancelled. Clinics have now resumed, but are running at around 60% of usual capacity under Covid restrictions, so the backlog continues to grow, with glaucoma patients at risk of irreversible sight loss due to delays in treatment.

Government Funding

The Scottish Government has recognised the acute problem facing Ophthalmology services due to backlogs within long-term caseloads. The Government scheme will pay community optometrists to undertake this work on a fee per patient basis.

Prioritisation of Glaucoma

It is proposed to commence these efforts with a scheme for glaucoma:

• glaucoma patients form a large, at-risk group in urgent need of attention
• there are defined patient groups within the caseload whose needs are suited to a shared care arrangement
• the development is aligned to national guidelines (SIGN, RCOphth) and initiatives such as NESGAT

Assessment:

Patient Cohorts

The Ophthalmology Department has identified an initial cohort of around 1000 hospital patients whose glaucoma care is currently delayed and who would be suitable for management or review by community optometrists on a shared or interim care basis. This includes the group of lower risk or stable patients who will be suitable for discharge to the care of NESGAT optometrists, once training and accreditation have been rolled out.

The cohort includes 3 sub-groups of patients whose interim review can be undertaken by any community optometrist along a common pathway:

• Glaucoma suspects
• Ocular Hypertension on or off treatment / pigment dispersion syndrome / pseudoexfoliation
• Treated Primary Angle Closure (post iridotomy / pseudophakia)

One further sub-group will follow a separate pathway, involving only optometrists with Independent Prescriber (IP) status, OCT and a Humphrey Visual Fields Analyser (HVFA):

• Early Primary Open Angle Glaucoma / Normal-Tension Glaucoma

Optometry Practices & Patient Access

The Primary Care Services Department has canvassed for interest among community optometrists. The response has been encouraging, with around 60 practices interested in offering glaucoma appointments. Practices have varying levels of training and equipment, but around 25 of the 60 can offer IP status, OCT and HVFA. All practices have, or have applied for, access to Clinical Portal (available to community optometrists on a read-only basis).

The scheme will increase local access to appointments, with care provided in up to 60 community optometry practices rather than across 7 acute sites. Where possible, patients will attend their referring optometrist. However, it is recognised that there may be access issues for patients with some practices, depending on the location and local travel infrastructure.

Protocols, Pathways and Administration

In the initial phase, patients within the scheme will not be discharged, but will remain under the overall care and responsibility of the hospital consultant.

Low risk Glaucoma monitoring protocols

Patients will be identified by a Consultant Ophthalmologist /Optom to the HES Co-ordinator. Patients will be distributed among participating practices via a pre-determined, postcode-based model, with practices receiving patients’ details by email as well as a clinical summary.

Community Optometry Contact Sheet

The clinical summary will also be made available for access via Portal. This should include the patient’s name, CHI, Date of Birth, Address, Telephone number.

Glaucoma Summary Form for Interim Visit

Patients will receive written communication from Consultant Ophthalmologist to explain the scheme and to inform them they are going to be contacted by Community optom regarding their next appointment. Draft of letter:

Glaucoma - Letter to Patients for Community Optometry

Practices will organise appointments directly with patients and undertake consultations and investigations according to an agreed protocol.

The Co-ordinator will keep a record of which patients have been seen and will ensure that the hospital records are updated accordingly.

The Optometrist will send a report to the Hospital Eye Service following each patient consultation within a maximum of 5 days of the consultation using the Ophthalmology Shared Care template available within SCI gateway.

SCI Gateway Referral Template Changes Required

The HES Co-ordinator must be informed within 5 days of any patient who, for any reason, does not attend their scheduled appointment at the practice. Template available via SCI Gateway.

Any Optometrist who has concerns regarding a patient’s condition or treatment should contact the Co-ordinator who will liaise with the consultant who will decide on a follow up.

There may be a requirement for patients to attend the community optometrist more than once before hospital follow-up is resumed, for instance to confirm the consistency of an abnormality detected at the initial visit, such as raised intra-ocular pressure that may be related to a compliance issue.

As this service approaches the end of its current funding arrangements, the Co-ordinator will make the necessary arrangements to ensure patients are appointed in line with their review timetable to hospital outpatient links for their ongoing review.

Data Protection

The Community Optometry Practice agrees to comply with the terms of the Data Protection Act 1988 and GDPR.

Payments and Costs

Payments to the optometry practice in line with the fee structure determined by the Scottish Government will be at a rate of £65 per patient. Payment will be triggered by submission of the outcome form to the Hospital Eye Service through SCI Gateway and made to practices on a monthly basis via Primary Care Support and Practitioner Services.

Based on one community attendance per patient, the cost of community-based reviews for an initial tranche of 1,000 patients will be £65,000. Confirmation will be required from Scottish Government on the payment arrangement for repeat visits.

Future Development

The processes and outcomes will be kept under review over the period of the scheme to capture learning for potential future expansion of community optometry input to this and similar groups of patients. This has the potential to develop a platform for a longer-term shift in the balance of care, subject to sustained funding.