New outpatient tariffs and the impact on ophthalmology – managing change for commissioning services
22 February 2017
The RCOphth has issued a further response to the December 2016 statement on how the new outpatient tariffs place unnecessary pressure on departments to discharge patients at a time when there is no suitable community care option available. You can read the response below or alternatively download it as a pdf.
What are the potential patient safety risks in the commissioning of ophthalmology activity and how can they be alleviated?
Ophthalmology, as a specialty, recognises the need for changing and modernising the delivery of care as demand has increased incrementally year on year. It is a high volume specialty (over 8% of all outpatients seen and 7% of all surgical activity) and relates to a variety of very different disease management requirements – from conditions that will not need any follow up through, for example, high volume cataract surgical pathways to those that require regular assessment and treatment appointments for several years, or even for life. This, in itself, is a challenge. The risk of unnecessary loss of vision due to failure to manage essential follow up outpatient appointments effectively is well recognised.
The combination of an increasing prevalence of ophthalmic disease in an aging population, new treatment availability and NICE guidelines has increased demand for ophthalmology services without a matching increase in ophthalmic workforce or infrastructure support. The lack of capacity is exacerbated by the 18 week RTT, which can act as a perverse incentive to prioritise new over follow up patients. There is compelling evidence, from sources including the NPSA, the National Reporting and Learning System (NRLS), CQC inspections, patient and charity groups, and The Royal College of Ophthalmologists British Ophthalmological Surveillance Unit survey, that hundreds of patients have suffered irreversible loss of vision due to delay in ophthalmology outpatient follow up attendances from 2003 onwards, with ongoing evidence of about 200 such cases still occurring annually in the UK.
The recent changes in outpatient tariff payments have the potential to compound this situation by putting further pressures on providers to reduce or delay clinically appropriate follow up appointments and even creating the potential that recommended chronic disease pathways become financially unviable and endanger patient safety. Currently there is a lack of established provision to undertake the required care in a community or primary care setting. The use of inventive and supportive local contract variations could potentially alleviate this risk, whilst work and training continue to increase community and secondary care capacity. In particular, it is important to:
- 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
What is the evidence base for commissioning outpatient activity?
The use of new to follow up ratios across all ophthalmic care is a crude way of commissioning outpatient activity. In many conditions regular long term monitoring with or without outpatient procedures (eg intravitreal injections/ laser treatment) are part of nationally recommended treatment pathways and this is particularly true for chronic retinal disease and glaucoma. Most notably these include The National Institute for Health and Care Excellence (NICE) approved interventions for the management of age related macular degeneration, diabetic macular oedema (DMO) and retinal vein occlusion (RVO) and NICE guidance for the management glaucoma.
These high-risk outpatient-based active treatment pathways, which reflect chronic patient management, should be considered separately to routine outpatient care, and commissioning guidance is available from the College. Expected new to follow up ratios for these particular patient groups would be approximately 1:16 in high risk glaucoma and 1:12 in age related macular degeneration and diabetic eye disease.
In comparison, many high volume ophthalmic conditions require no or minimal follow up and these should also be noted and their n:fu ratios identified.
What are the possibilities for new ways of working in delivering ophthalmology outpatient activity?
There are many examples of new and innovative ways of delivering patient care. These involve ways to:
- decrease the number of false positive referrals into secondary care
- optimise secondary care efficiency and value
- deliver care in different settings through shared or community care and virtual clinics.
Commissioners and providers from all disciplines in the ophthalmic sector (optometry, medical, nursing, orthoptic, ophthalmic technicians) should work together with the NHS England Local Eye Health Networks to maximise potential and ensure good clinical governance of such innovative pathways. Examples, and how they can be commissioned and developed can be found in:
- RCOphth The Way Forward publications
- Commissioning Frameworks produced by the Clinical Council for Eye Health Commissioning (CCEHC)
- RCOphth Commissioning Guidance for Glaucoma and Cataract
- College of Optometrists and the Local Optical Committee Support Unit (LOCSU)
More may emerge from the ongoing ophthalmic Getting It Right First Time (GIRFT) Project. New schemes require eye health care professionals who are adequately trained to perform enhanced roles – these are outlined in the recent Common Competency Framework for eye care professionals. For examples – see Appendix 1. Appendix 2 outlines important principles regarding who to consult and how to commission care for STPs, across previous CCG boundaries.
How to assess quality, safety and cost effectiveness of secondary and surgical ophthalmic care
The RCOphth has developed simple self-assessment Quality Standard tools for secondary care for all the major ophthalmic subspecialties, children/young people and groups of vulnerable patients, which are recommended to be reassessed at least annually. These provide a rapid assessment of quality and safety in units and networks of secondary ophthalmic services and can be used by providers and commissioners for assurance and to drive quality improvement.
The College has also produced a draft Model Ophthalmic Hospital tool which can be used for assessment and more benchmarks for inclusion will emerge as the GIRFT project progresses.
- Surveillance of sight loss due to delay in ophthalmic treatment or review: frequency, cause and outcome. Authors: B Foot and C MacEwen http://www.nature.com/eye/journal/vaop/ncurrent/full/eye20171a.html
- The Way Forward was commissioned by the RCOphth 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 information aims to offer a helpful resource for members who are seeking to develop their services to meet capacity needs https://curriculum.rcophth.ac.uk/standards-publications-research/the-way-forward/
- “Preventing delay to follow-up for patients with glaucoma”. NRLS 0959 Rapid Response Report, NPSA; 11 June 2009. http://www.nrls.npsa.nhs.uk/alerts/?entryid45=61908
- Cambridge University Hospital NHS Foundation Trust CQC report 2015. http://www.cqc.org.uk/sites/default/files/new_reports/AAAD0110.pdf
- Saving money, losing sight. RNIB 2013. http://www.rnib.org.uk/sites/default/files/Saving%20money%20losing%20sight%20Campaign%20report_0.pdf
- AMD services survey report. Macular Society and The Royal College of Ophthalmologists 2013. https://curriculum.rcophth.ac.uk/2014/01/survey-results-show-under-resourced-eye-clinics-put-patients-sight-at-risk/report?
- NICE Technology Appraisals for Aflibercept – TA294: Age Related Macular Degeneration. NICE 2013 https://www.nice.org.uk/guidance/ta294,
- TA305: Macular oedema from CRVO. NICE 2014 https://www.nice.org.uk/Guidance/ta305,
- TA346: Diabetic Macular Oedema. NICE 2015 https://www.nice.org.uk/guidance/ta346?unlid=2977097852016927201040,
- TA409: Macular oedema from BRVO – NICE 2016 https://www.nice.org.uk/guidance/ta409,
- Glaucoma; diagnosis and management CG 85. NICE 2009. https://www.nice.org.uk/guidance/cg85.
- Glaucoma commission guide. The Royal College of Ophthalmologists 2016. https://curriculum.rcophth.ac.uk/wp-content/uploads/2016/06/Glaucoma-Commissioning-Guide-Recommendations-June-2016-Final.pdf
- Commissioning better eye care. Age related macular degeneration. The Royal College of Ophthalmologists and College of Optometrists, 2013, https://curriculum.rcophth.ac.uk/wp-content/uploads/2014/12/AMD-guidance-25-11-13-2013_PROF_262.pdf
- New to follow up (N:F) ratios in ophthalmology outpatient services. The Royal College of Ophthalmologists 2011. https://curriculum.rcophth.ac.uk/wp-content/uploads/2014/12/2011_PROF_114_New-to-follow-up-ratios-in-ophthalmology-outpatient-services.pdf
- Ophthalmology common clinical competency framework. The Royal College of Ophthalmologists 2016. (https://curriculum.rcophth.ac.uk/2016/01/competency-framework/
- Community ophthalmology framework. Clinical Council for Eye Health Commissioning. http://www.college-optometrists.org/en/utilities/document-summary.cfm?docid=04657CE1-1824-4058-B8C6ADC4E40A9A76
- Primary eye care framework. Clinical Council for Eye Health Commissioning. 2016. http://www.college-optometrists.org/en/utilities/document-summary.cfm?docid=8A93D228-AC28-4E6E-98AF94C62C0F8442
AMD – age-related macular degeneration, deterioration or breakdown of the eye’s macula due to increasing age.
RVO – retinal vein occlusion, a blockage of the retinal veins causing poor blood supply and swelling (oedema) in the retina.
CCEHC – Clinical Council for Eye Health Commissioning, set up to provide national clinical leadership for eye health. It brings together leading patient and professional bodies involved in eye health (includes The Royal College of Ophthalmologists and the College of Optometrists). For a full list of members: http://www.college-optometrists.org/en/utilities/document-summary.cfm?docid=8AFDDCBB-9BAA-44EF-8CC2504ED0CE2B4D
CQC – The Care Quality Commission monitors, inspects and regulates hospitals, care and social care services. www.cqc.org.uk
CQUINs – Commissioning for Quality and Innovation. These are payments intended to encourage care providers to share and continually improve the delivery of care. Commissioning for Quality and Innovation
DNA – Did not attend – The patient did not attend an appointment and no explanation was given in advance of the appointment. DNAs can be the result of many causes, including visually impaired people receiving notification of appointments in inappropriate forms.
KPI – Key Performance Indicator, a measurable value that demonstrates how effectively an organisation is achieving key objectives.
LOCSU – local optic support unit, supports Local Optical Committees (LOCs), community optometrists and opticians across England to work with local commissioners in developing local community based eye health services.
NICE – The National Institute for Health and Care Excellence provides national guidance and advice to improve health and social care. https://www.nice.org.uk/about
NICE Technology Appraisals – assess the clinical and cost-effectiveness of health technologies, such as new pharmaceutical and biopharmaceutical products, to ensure that all NHS patients have access to the most clinically- and cost-effective treatments available.
NRLS – The National Reporting and Learning System is a central database of patient safety incident reports.
NSPA – National Patient Safety Agency. in June 2012 the key functions and expertise for patient safety developed by the NPSA transferred to the NHS Commissioning Board Special Health Authority.
RTT – Referral to treatment. The NHS Constitution sets out that patients should wait no longer than 18 weeks from GP referral to treatment. https://www.england.nhs.uk/resources/rtt/