Optimising the Primary/Secondary Care Interface in Eye care Services Richard Best Belfast Health and Social Care Trust

Ophthalmology Hospital Eye Service One of the largest outpatient specialties in NHS One of the largest outpatient specialties in NHS Rapidly evolving Rapidly evolving Changed from observation to intervention Changed from observation to intervention High volumes of patients High volumes of patients Day case surgery Day case surgery

Ophthalmology Accurate diagnosis Accurate diagnosis Technological advances Technological advances More treatments More treatments More patients More patients

Pressures on Ophthalmology More referrals More referrals Ageing population Ageing population Chronic disease management-diabetes COAG, ARMD Chronic disease management-diabetes COAG, ARMD Limited resources (Staff/Equipment/Facilities) Limited resources (Staff/Equipment/Facilities) Guidelines informing practice (NICE) Guidelines informing practice (NICE)

NHS in UK Change in last 10 years Large increase in funding (6%GDP to 11%GDP) Large increase in funding (6%GDP to 11%GDP) Macromanagement tools (access targets) Macromanagement tools (access targets) Targets have become standards Targets have become standards ? Sustainable ? Sustainable

Current Problems Demand exceeds supply Demand exceeds supply 10% rise in number of referrals 10% rise in number of referrals Heavy use of IS to increase provision Heavy use of IS to increase provision Financial constraints Financial constraints

Solutions Increase funding/increased provision Increase funding/increased provision Waiting lists Waiting lists Effective use of resources Effective use of resources Look at current model – is it appropriate? Look at current model – is it appropriate?

Increased Funding/Provision Outpatient waiting lists behave as a complex system that resists change Outpatient waiting lists behave as a complex system that resists change Appear self regulating power laws Appear self regulating power laws Obey their own laws Obey their own laws Similar to traffic jams/avalanches Similar to traffic jams/avalanches Shorten waiting lists increase referrals Shorten waiting lists increase referrals Smethurst et al Nature 2001

Ideal Model Patient Flow Tertiary Care Secondary Care Primary Care General Population

Actual Model in Ophthalmology Population Primary Care Secondary Care Tertiary Care

Primary Care GPs GPs Gatekeepers Gatekeepers Triage and assessment Triage and assessment Provide appropriate treatment Provide appropriate treatment

Primary Care in Ophthalmology GPs GPs Undergraduate training Undergraduate training GPWSi s (postgraduate training) GPWSi s (postgraduate training) Allied Health Professionals Allied Health Professionals Ophthalmologists Ophthalmologists

Primary Care in Ophthalmology Embrace skills of those working in primary care settings Embrace skills of those working in primary care settings Decentralisation of heavily populated central units Decentralisation of heavily populated central units Allow recruitment of flexible practitioners to practice in Primary care setting but with strong links to the centre Allow recruitment of flexible practitioners to practice in Primary care setting but with strong links to the centre

Primary Care in Ophthalmology Refinement of referrals Refinement of referrals Referral guidelines (Local development) Referral guidelines (Local development) Shared Care for chronic conditions Shared Care for chronic conditions Managed Clinical Networks Managed Clinical Networks

Primary Care in Ophthalmology Referrals Good referral should ensure that the right patient accesses the right service or specialist at the right time Good referral should ensure that the right patient accesses the right service or specialist at the right time

Interventions to Improve Quality of Referrals Triage Triage Referral guidelines Referral guidelines Active educational input from local secondary care specialists Active educational input from local secondary care specialists Structured referral sheets Structured referral sheets

Shared Care Post op reviews Post op reviews Chronic diseases Chronic diseases Telemedicine Telemedicine Combined clinics (specialist and primary care team) Combined clinics (specialist and primary care team)

Managed Clinical Networks Linked groups of health professionals from primary secondary and tertiary care working in a coordinated manner unconstrained by professional and organisational boundaries Linked groups of health professionals from primary secondary and tertiary care working in a coordinated manner unconstrained by professional and organisational boundaries

Thank you