NHS Coventry and Warwickshire ICB has redesigned its referral pathway for secondary care ophthalmology treatment using a new electronic eye care referral system and a hub-based approach to deliver the new service across the care system.
Ophthalmology referral pathways had differed across Coventry and Warwickshire with three main pathways in place, based on the former clinical commissioning group boundaries, and multiple referral routes. Patient choice was limited in some cases and GPs were having to manage referrals from optometrists, adding to the administrative burden on practices.
When a new electronic eyecare referral system was commissioned for ophthalmology by the NHS England Midlands regional team, this presented the ICB with an opportunity to redesign referral pathways and address inequity across the system.
Our objectives were to:
- Offer patients choice in where they could access treatment
- Refer patients to appropriately accredited provision first time, reducing off-contract activity
- Enable direct referral from optometry practices to secondary care, reducing the burden on GPs.
Coventry and Warwickshire ICB appointed NHS Arden & GEM CSU’s healthcare transformation team to drive the project, with an ambitious goal of implementing the changes within just six months.
The approach
This project had three phases:
- Assessing the current approach to eye care referrals and building a case for change
- Establishing the central hub and electronic referral system
- Rollout of the new pathway.
We began by developing a thorough understanding of the existing processes in place across the system to understand the scale of the service, existing referral routes and opportunities to optimise provision. This process identified inconsistencies in the level of choice patients were being given in terms of location, timing and provider. Some options were only available via GP referral while others could be referred directly by the optometrist. Combining this information with data from optometrists and providers enabled us to develop a baseline for the service, understand the volume of referrals and identify any issues with the existing referral process.
As part of the project, the six NHS and independent sector providers ensured that the information available on their ophthalmology services on the national referral system was accurate, reducing the risk of inappropriate referrals.
Establishing the ophthalmology coordination service
Using this baseline data, Arden & GEM’s healthcare transformation team project team worked closely with ICB colleagues to develop a new model for referrals, which was informed by:
- lessons learned and best practice from early adopter sites
- likely referral volumes and costs for the new pathway
- engagement with the Local Optical Committee (LOC) and providers to construct as-is and to-be process maps, ensuring clinical safety and business continuity protocols were in place.
From the outset, the ICB was keen to explore the potential benefits of a hub-based approach to coordinating referrals due to variation in electronic patient record systems and timelines within the ICS. It became clear from the research that this could offer significant benefits, including timely implementation, increased consistency and improved patient experience.
The ophthalmology coordination service (OCS) was therefore set up to receive all the referrals from optometrists using the new electronic eye care referral system and to identify suitable options based on the referral. The OCS team then contacts patients to offer them a choice of options according to their own priorities. Crucially, the resulting referral is then sent to the provider using the national electronic referral system. This avoided the need for providers to switch to different systems, simplifying the process.
The introduction of the newly commissioned electronic eye care referral system, Cinapsis, gave us the opportunity to replace multiple referral pathways with one consistent system that all optometrists could access. We worked closely with the system provider to tailor the referral forms to suit the hub model and options available within Coventry and Warwickshire, and training was provided for all those needing to use the new system.
Stakeholder engagement and joint working
Partnership working has enabled this pathway redesign to be developed and deployed at pace. Stakeholders including the ICB Elective Care team, local optical committee (LOC), secondary care ophthalmology treatment providers, primary care, Cinapsis and NHS England’s regional team were engaged throughout.
The chair of the LOC attended project meetings with the ICB and wider project team, providing clinical input and expertise as well as ensuring the needs of optometrists were understood. The LOC was also instrumental in cascading information to its members, enabling sign up to the new electronic eye care referral system and facilitating the rollout.
Similarly, once the OCS provider had been appointed, they were pivotal to the success of the project, bringing their expertise of how to manage referrals through the pathway. The project team also worked closely with the regional clinical safety officer to assure the clinical safety report, standard operating procedures and business continuity plan.
Implementation and learning
Rollout was split into three phases. First was a number of early adopters, second was South Warwickshire, and then finally Coventry, Rugby and North Warwickshire. Working with the LOC leads, we adopted a ‘cyclical rollout process’, using iterative testing and learning to increase the number of optometry practices included in each cycle. Over 90% of optometry practices have been onboarded to date.
The new simplified referral pathway was put in place within six months and has already delivered:
- faster and more convenient routine and urgent referrals to appropriate providers
- greater and more consistent patient choice
- improved visibility of referrals and progress for monitoring purposes
- reduced administrative burden on GP practices
- more robust data about referrals and provision via the OCS.
GP practices are also better informed of the referral progress and outcomes through routine updates which they can then attach to their patients’ records.
Critical to the success of this project has been the close working relationship between the ICB lead and the project team, as well as the partnership approach. By working closely with those affected by the changes, the ICB has been able to capitalise quickly on the benefits of the new EeRS and develop a new pathway which improves patient choice, reduces demand on GPs and provides a more consistent approach across the ICS.
Laura Nelson is chief integration officer at NHS Coventry and Warwickshire ICB and Julia Markham is managing improvement consultant at NHS Arden & GEM CSU
