New Care Pathways in Glaucoma

1. Stephen A. Vernon DM FRCS FRCOphth DO New Care Pathways in Glaucoma DEPARTMENT OF OPHTHALMOLOGY UNIVERSITY HOSPITAL NOTTINGHAM UK

2. UK population by age - 2001 Age range

3. BMES PREVALENCE OF POAG <60 60-69 70-79 >80 Age Group

4. Estimated numbers of glaucomas in UK by age No in 1000s Age

5. Estimated numbers of glaucomas in UK by age No in 1000s Age Over 65s to increase by 20-25% by 2020

6. A model of onset of a slowly progressive degenerative disease Clear cut disease No disease Grey area Ageing increases size of grey area Overlaps depend on definitions

7. Elderly population increasing More cases detected (esp NTG) Low ratio of ophthalmol. : patients in UK Increasing specialisation and investigations Changes in training reduces clinic staff Drive for low target pressures – more visits Medical management options greater - more visits Demand for “patient centred care” – patient choice, C&B New targets for first OPD visits lead to bow-wave of follow up patients Desire of PCT to save money Payment by results The Optometrists lobby. Factors driving change in glaucoma

8. Demographic details of presenting patients Past (1980) 63% via optometrists Mean age 70.6 Mean IOP 31.7mmHg 33% late 10% reg blind few false positives

9. Demographic details of presenting patients Present 98% via optometrists Mean age reducing Mean IOP reducing fewer present late rare to register blind at presentation false positive referrals a problem

10. Percentage of referrals diagnosed as normal at first SAV Glaucoma Clinic

11. Diagnostic breakdown 2000 – SAV clinic % Nearly 30% OHT and suspects

12. Typical Eye department increase in Outpatient visits

13. New meds have lowered surgical rates

14. Increase in glaucoma medications prescribed 1995 - 2004 total UK data by month All Beta blockers Xalatan Timolol Cosopt

15. The glaucoma clinic snowball phenomenon

16. Workload calculation for UK ophthalmologists 380,000 glaucoma patients in UK 540 patients per consultant Average 2.5 visits/yr 1600 visits/yr 3 clinics available 533 visits per clinic for 42 weeks 13 glaucoma pts/clinic (if all diagnosed)

17. Workload calculation for UK ophthalmologists 13 glaucoma pts/clinic (if all diagnosed) 50% diagnosed But 200 suspect referrals/yr + review suspects/OHT 6 per clinic 12.5 glaucoma related patients every clinic If all consultants “do” glaucoma Glaucoma accounts for only 25% of OPD visits

18. The current “English” care pathway Suspects “detected” by optometrists Referred to GP by letter (GOS18) GP sends letter + GOS18? to patient choice co-ordinating centre Patient rings centre to choose secondary provider Choice centre sends letter to secondary provider Letter vetted by ophthalmologist Patient sent appointment(s) for clinic CaB is changing this Diagnosis glaucoma, suspect or normal (1/3 each) HES manages glaucomas and most suspects But …………..

19. +

20. Potential outcome SS HES

21. The new DOH Eyecare Pathways

22. Membership of DoH Working Party Stephen Vernon (R C Ophth Nottingham) Chair Nicholas Astbury (R C Ophth Norwich) Mike Nelson (R C Ophth Sheffield) Jane Futrille (GOC) Trevor Warburton (AOP) Steve Taylor (FODO) Michael Banes (Coll Optom) Chris Packford (Assn Disp Optom) Tim Smith (RCGPs) The late John Keast-Butler (BMA)

23. Problems considered Suspect glaucoma accounts for 16-20% of new referrals to the HES and an even larger number of return visits (25-30%). Increased referrals are likely as population ages. 3. Early glaucoma is not easy to diagnose or to exclude with certainty. This leads to “defensive” continued observation in the HES.

24. Problems considered – 2 Incorrect perceptions - glaucoma causes a rapid progression to blindness - early diagnosis is essential to prevent this in most or all cases. 5. Other conditions commonly co-exist with glaucoma, particularly in the elderly. Excluding progression in an established case may be difficult - often requires considerable expertise and skill.

25. Problems considered - 3 7. Not all patients with glaucoma require treatment on diagnosis and some never do. 8. Treatment may have side effects which can be life threatening. 9. The quality of data in referrals from community optometrists is highly variable.

26. Current position (Jan 2003) 4 strategies to relieve HES pressures Reduce the number of referrals to the HES (e.g. the Manchester Super-optometrist in the community scheme) Increase the capacity within the HES (e.g. the Nottingham and Bristol in-house optometrist schemes) Reduce the number of glaucoma patients seen in the HES (various UK shared care projects) Initiative clinics/change of job plan

27. Primary objective - Convert patients from secondary to primary care Potential advantages Reduces workload for secondary care – allows reduced waiting times for other ophthalmic conditions. Increase in patient quality of life (reduced travel, cost, waiting times etc.). Cost minimising analysis may be positive for primary care. 4. Increases potential for implementation of National Protocols.

28. Potential Problems Previous studies failed to indicate potential value of shared care in the community more expensive relatively low percentage of glaucoma patients suitable high “referral-back” rate to HES Current skill level in primary care insufficient who would train/do the training do the trainers and/or trainees have the time/desire to train?

29. Potential Problems -2 3. Defining who has responsibility for the patient. 4. Legal issues – prescribing rights for non-medical staff will be essential if they are to manage all but low risk OHT and suspects. 5. IT, audit and clinical governance/confidentiality issues.

30. Glaucoma care in the Community Pre-requisites for successful care Capacity Trainability Professionalism Optometrists and OMPs are best suited to provide care

31. Non-ophthalmologist care of glaucoma Two strategies Train all optometrists to minimum level Train some optometrists to higher level Principle of the “Specialist Optometrist” (OMPs could also assume similar role)

32. Non-HES care of glaucoma Operational principles Open to all optometrists and OMPs Accreditation and revalidation system Audit and clinical governance safeguards Referring optometrists work to referral guidelines/protocols

33. Main WP Recommendations 1Community optometrists are encouraged to conform to College guidelines for referral of glaucoma suspects. 2HES services are encouraged to utilise optometrists to assist in glaucoma care within the HES. 3Community refinement of optometric referrals is established utilising OMPs and specialist optometrists. Community care of “straightforward” glaucoma cases by OMPs and specialist optometrists is established. The National Screening Committee considers chronic glaucoma as a candidate for formal screening.

34. Main WP Recommendations 1Community optometrists are encouraged to conform to College guidelines for referral of glaucoma suspects. 2HES services are encouraged to utilise optometrists to assist in glaucoma care within the HES. 3Community refinement of optometric referrals is established utilising OMPs and specialist optometrists. Community care of “straightforward” glaucoma cases by OMPs and specialist optometrists is established. The National Screening Committee considers chronic glaucoma as a candidate for formal screening. First 3 deemed priorities, fourth requires legislation changes

35. The 5 Care Pathways Care Pathway 1 Ocular Hypertension Care Pathway 2 Glaucoma without other eye disease Care Pathway 3 Glaucoma suspect on discs and/or fields Care Pathway 4 Glaucoma in presence of other significant eye disease Care Pathway 5 Refinement of community optometric referrals

36. The 5 Care Pathways Care Pathway 1 Ocular Hypertension Patient maintained in primary care following confirmation Yearly monitoring by SpO + or – treatment on protocol (IOPs, fields, discs) SpO has responsibility

37. The 5 Care Pathways Care Pathway 2 Glaucoma without other eye disease If not “advanced” – remains in primary care Care shared between SpO and HES via IT link SpO decision following protocol – HES intervenes only if necessary Monitored by SpO following protocol If “advanced” – refer to HES HES has responsibility in pathway 2

38. The 5 Care Pathways Care Pathway 3 Glaucoma suspect on discs and/or fields Monitor by SpO yearly HES opinion (via IT link or appnt) if SpO considers possible neuro cause for field loss SpO Converts to other pathway as appropriate SpO has responsibility unless HES involved

39. The 5 Care Pathways Care Pathway 4 Glaucoma in presence of other significant eye disease SpO refers patient to HES HES may convert to pathway 2 if SpO agrees HES has responsibility

40. The 5 Care Pathways Care Pathway 5 Refinement of community optometric referrals SpO refers all but normals and very low risk suspects (inc OHT) to HES (SpO, as in all pathways, performs full exam inc pachymetry, imaging, fields etc) SpO has responsibility

41. Important features of new care pathways IT link continues to involve UK based Ophthalmologists Evidence based protocol driven care Readily auditable Will provide evidence base for changes in practice

43. At what stage is the DoH process – Bids for funds to pilot pathways invited (Sept 03) Approx 40 received (Early Oct 03) Short-listing completed (End Oct 03) 4 accepted for funding Pilots June 04 – May 06 DoH roadshows April/May 04 Pilots report early 2007 NECSSG first report on website www.modern.nhs.uk

44. Pathways are dependant on – Goodwill between optometrists and ophthalmologists Sufficient interest from optometrists Time/money for training Changes in regulations IT development/funding Enthusiasm of protagonists

45. Pathways are dependant on – Goodwill between optometrists and ophthalmologists Sufficient interest from optometrists Time/money for training Changes in regulations IT development/funding Enthusiasm of protagonists

46. 2002 survey

47. Capacity – WTE optometrists are increasing --- and still are! - now stands at approx 7800

48. Could it really happen? Workload calculations Protocol requirements Ophthalmologist time Training, supervision, monitoring Ophthalmologist motivation Funding

49. Workload calculations 172000 referrals for suspect glaucoma per year Referral refinement requires 53 WTE OSI ? 250 community optoms to be trained Should reduce referrals by 50% If community manages straightforward glaucomas – 820,000 patient visits in community per year would require additional 50 WTE optoms

50. Is it happening? Multiple “pilots” running as schemes (Nottm “in house” + OHT in community projects) Clinical competencies being defined RCO diplomas proving popular