Enhanced eye care in Wales – A new service

1. Enhanced eye care in Wales –A new service

2. What service do we want? • How did we get there? • How do we ensure it is fit for purpose?

3. What service do we want? • Appropriate, efficient, fit for purpose community eye care service for patients in Wales • Accessible for those who need it • Learn from previous eye care services • Updating and improving for patients

4. How did we get there?

5. Started with WECI Welsh Eye Care Initiative (WECI) Welsh Eye Health Examination (WEHE) Primary Eyecare Acute Referral Scheme (PEARS) Welsh Low Vision Service (WLVS)

6. Purpose of WECI Detect eye problems in individuals at high risk Enable early assessment of acute eye problems Provide an accessible low vision service

7. Perceived advantages Providing services close to peoples’ homes Reduced demand on GP and hospital resources More patients managed in primary care Better quality of referral from primary to secondary care Using facilities and personnel which were under-utilised

8. The Welsh Eye Health Examination An extended eye health examination For those who have an increased risk of sight-threatening eye disease would find losing their sight particularly difficult Patients may self-refer, or be referred by their GP WEHE

9. The Welsh Eye Health Examination - WEHE • Uniocular patients • Patients who are profoundly deaf –need sight to lip read • Patients with retinitis pigmentosa • Patients whose family origins are Black African, Black Caribbean, Indian, Pakistani or Bangladeshi • Those at risk of eye disease by other reasons of race or family history

10. Black and Minority Ethnic groups Increased risk of sight-threatening eye disease:

11. PEARS Anyone with an eye condition that needs urgent attention Patients can self-refer An appointment within 24 hours The Primary Eyecare Acute Referral Scheme

12. Optometrists must have specified equipment in their practices Optometrists did theory training and were assessed Approximately 90% of all optometrists in Wales are accredited Training and accreditation

13. Assessments

14. What optometrists learned Increased use of a Volk lens and/or dilating a patient (23.4%) Increased confidence dealing with cases of ocular pathology (17.7%) 27.5% described the experience as ‘traumatic’

15. WEHE & PEARS Service Evaluation

16. Evaluation An evaluation was carried out Customised records cards were filled in by optometrists Referrals scrutinised

17. WEHE & PEARS evaluation • 6,432 record cards were reviewed • 66% of patients were managed in practice (i.e. not requiring GP or Hospital visit) • 99% appropriate referrals by optometrists • 100% patients satisfied Sheen NJL et al. Novel optometrist-led all Wales primary eye-care services: evaluation of a prospective case series Br J Ophthalmol 2009;93:435-438

18. Welsh Low Vision Service (WLVS)

19. Welsh Low Vision Service A rehabilitation service for people with a visual impairment Based in 185 optometry practices Practitioners accredited by Cardiff University Anyone can refer including patients themselves WLVS

20. Welsh Low Vision Service A range of low vision aids

21. Welsh Low Vision Service - Holistic • Multi-disciplinary sessions during training • Training for rehabilitation workers and specialist teachers

22. Just as effective as the hospital service • Comparing hospital and community low vision services • No significant difference in clinical outcomes • No significant differences in user centred outcomes • Disability significantly reduced after low vision service • Improved access Court H et al. British Journal of Ophthalmology 2010

23. Proven services that are effective • Low Vision • PEARS/ WEHE • Why change?

24. Changes to PEARS/ WEHE needed • There are categories of patients at risk of eye disease that were not covered • Ethnicity categories not well defined • PEARS/ WEHE/ WECI can be confusing • No permanency to services

25. Changes to PEARS/ WEHE needed • Clinical guidelines had changed • Focus On Ophthalmology • Potential to alleviate hospital eye service capacity issues

26. What has changed • Updated • Name of services • Structure – further categories • Clinical guidelines • Referral forms • Service guidelines

27. Name of services • Welsh Eyecare Initiative now becomes Wales Eye Care Service (WECS) • PEARS/ WEHE are now amalgamated to single service Eye Health Examinations Wales (EHEW) • Welsh Low Vision Service now becomes Low Vision Service Wales

28. Eye Health Examination Wales (EHEW) • Introduces new categories for: • referral by DRSSW • monitoring dry AMD yearly • cataract referral refinement

29. Eye Health Examination Wales (EHEW) • Other improvements: • Reporting of ethnicity and clarification of ethnicity categories • ONS Census linked

30. Eye Health Examination Wales (EHEW) • Guidelines for referrals, emphasis on: • Optoms to repeat Intra-ocular pressure readings with Applanation tonometry • Optoms to repeat visual field examinations

31. Clinical guidelines • AMD monitoring - Dry AMD • Advice about lifestyle and what to do if sudden drop in vision etc • Cataract – Referral refinement • Guidance about discussing with the patient and a questionnaire for the patient to complete

32. Referral and report forms • New referral to ophthalmology form • Paper and electronic • New report to GP form • Paper and electronic

33. Referral form Report to GP

34. EHEW How do we ensure it stays fit for purpose?

35. Evaluation and Audit • Service guidelines and new forms make it easier • Regular audit • Evaluation of referrals • Findings from audits will feed into training

36. Training • Benefits gained should outweigh cost • Training programmes should focus on evidence based practise and should always display strong links to desired outcomes (Mays 2004) • We need to ensure it has an positive effect on behavior

37. Training – peer review • Peer review as a vehicle for communicating results of audits and changes to service • Cases used to embed learning outcomes for optometrist practitioners • Discussing cases makes it ‘real’ • Evaluate impact that peer review has

38. Service review

39. Conclusions • We seek to have the best service possible for those patients who need it most • We will continue to evolve the service by evidence based evaluation and training • We believe that we have a service that will be fit for purpose

40. Ensuring changes are communicated • GPs • Ophthalmologists • Third sector organizations • Other healthcare workers • Patients!

41. Without whom.. • WG- Richard Roberts & Sarah O’Sullivan-Adams • OW – Sali Davis & Mike George • WOC – Ian Jones & committee • WOPEC – Barbara Ryan • Optometrists in Wales

42. Thank you Questions?