Patient are benefitting from being able to be seen closer to home for minor eye conditions thanks to a scheme commissioned in Medway, Kent
Patient are benefitting from being able to be seen closer to home for minor eye conditions thanks to a scheme commissioned in Medway, Kent
The NHS sight testing contract, provided under the General Ophthalmic Services (GOS), funds optometrists to ‘test sight’. This service is designed to enable certain groups of people (namely those under 19 who are in full time education, those over 60, those on low income and those in certain medical categories) to have a sight test funded by the NHS. The ‘sight test’ is defined as determining whether or not a person needs spectacles, and if so what prescription they need for this. When an optometrist (or doctor) tests the sight of a person he or she must also, by law, perform certain health checks. These include examining the front and back of the person’s eye and ‘such other examinations as appear necessary’ for the purpose of detecting signs of abnormality of disease.
Because the GOS contract is designed as a sight testing service rather than an ophthalmology service, people who require other ophthalmic care – such as those who have the symptoms of dry eye, conjunctivitis or who notice flashes and/or floaters in their vision are not covered by this service, as their complaint is unrelated to needing spectacles. Historically these patients had two alternatives: they could pay for a private examination by the optometrist or they could go to their GP or the local hospital. As a result, many patients self-presented to the hospital with minor eye conditions that could be safely and cost-effectively be managed within primary care. Since 2009 in Medway there is now a third option – the patient can be seen by a participating PEARS (Primary Eyecare Acute Referral Service) optometrist, free of charge to the patient. The aim is to avoid unnecessary trips to hospital which both inconvenience the patient and prove a more expensive option for the NHS.
Optometrists who chose to participate were accredited after they had undergone additional training, arranged by the Local Optometric Committee (LOC). This consisted of distance learning lectures and a five-station objective station clinical examination (OSCE). Accreditation is maintained by yearly refreshers and reaccreditation sessions every three years. In order to participate, optometrists need to be able to manage patients who present with symptoms of flashes and floaters, which could indicate a retinal tear or detachment, and be able to epilate ingrowing eyelashes. Any patient who presents with an uncomfortable red eye is examined using a slit lamp and appropriate staining agent.
The PEAR service specification sets out a certain level of equipment that optometrists must have. This includes a slit lamp, tonometer, threshold-controlled visual field testing equipment that produces a printed field plot, ophthalmoscope and Volk lens, epilation equipment and diagnostic drugs. These pieces of equipment are almost universally found in all optometric practices, and so no additional capital investment is required by the optometrist. For consistency and clinical governance, the specification sets out patient pathways for the various conditions that patients may present with using the service. These pathways are for:
– Lids, lashes and tears.
– Corneal problems.
– Flashes and floaters.
– Loss of vision.
– Red eye.
– Vascular abnormalities.
– Headache and migraine.
– Other ocular emergencies.
It is a requirement that participating optometrists must, within reason, be able to offer a PEARS examination on the same day that the appointment has been requested, or within 24 hours (excluding weekends and public holidays).
Initially patients could only access a PEARS appointment if they were referred by the GP with guidance being produced for GPs to help them to ascertain whether to refer a patient who presents with an ophthalmic condition to a PEARS optometrist or to the hospital. Referral routes have now been opened up to enable referrals to be made by other practitioners as well as enabling patients to self-refer into the service.
Outcomes
Performance and activity under the LES is monitored. Figure 1 shows the numbers of appointments used under the scheme. Figure 2 shows a breakdown of the conditions for which patients were seen since April 2013.
Patient satisfaction, as evidenced by a questionnaire, was measured for the period 1 Nov 2010 to 3 March 2011. More than 200 patient questionnaires were returned and analysed.
Figure 3 shows the responses for patients who were referred by their GP, and Figure 4 shows the responses for those who self-referred under the scheme.
As you can see from Figure 3, only a small number of patients were concerned about being seen by an optometrist, and the overall satisfaction rating was very high.
Bexley, Bromley and Greenwich
Following on from the successful PEARS in Medway, Bexley, Bromley and Greenwich (BBG) primary care trusts in South East London implemented a similar scheme in 2011. A total of 43 optometrists received training and accreditation across BBG.
Just over three quarters (76%) of patients were seen within 24 hours of the GP referral.
A sample of the number of PEARS appointments by condition is shown in Figure 4.
As for Medway, patient satisfaction with the service in BBG was high, with comments such as ‘I was very happy with the quick and efficient service’, ‘Very helpful and explained things fully’, ‘Excellent service from the optometrist and he put my mind at rest’ and ‘The service seems like a good idea and worked well for me’.
Feedback from GPs about the service is that longstanding chalazion should be referred for excision, and entropion should be removed from the list of conditions seen under PEARS, but eyelash removal should remain.
Other opportunities for managing patients within the community
There are other opportunities for managing ophthalmology patients within the community. For example, NHS West Kent was the first primary care trust in England to instigate a repeat measures scheme to enable optometrists to repeat visual fields and/or intra-ocular pressure measurements to reduce the number of false positive referrals for patients who are suspected of having glaucoma or ocular hypertension as a result of a sight test. NHS West Kent also has a system whereby adult ophthalmology referrals, except those for patients with suspected wet age-related macular degeneration, are triaged by a clinician before deciding whether the patient can be managed within the community. If the triager assesses that the patient can be seen in the community the patient is given the option of being seen by a member of the community ophthalmology team (COT). The COT consists of optometrists with special interest who work in a variety of settings (some in optometric practice and some in alternative settings) and one GP with a special interest in ophthalmology. Some optometric members of the COT are also independent prescribers, which gives them a wider range of therapeutic options than their non-prescribing colleagues.
The combination of repeat measures, PEARS and the COT means that as many patients as possible are being successfully managed within the community. This frees up the secondary care provision to concentrate on seeing the patients that they need to see. With the number of patients who need to be seen by the hospital eye service showing no sign of abating, opportunities for the primary and secondary care sectors working together have never been more important.
Acknowledgements
The author would like to thank Niall O’Kane for his comments on a draft of this article, and Pam Bridges and David Parkins for providing the outcome information for the PEARS in Medway and BBG respectively.
Further information
The Local Optical Committee Support Unit has produced model pathways on enhanced services including PEARS and repeat measures. See www.locsu.co.uk/enhanced-services-pathways/
