1. Prudent Eye Care & Clinical Prioritisation: Reconciling Risks & Waits
Graham Shortland: Medical Director
Cardiff & Vale UHB
Michael Austin: Consultant Ophthalmologist
Abertawe Bro Morgannwg UHB

2. Outcomes & Accessibility
OUTCOMES – (to be achieved, with data to confirm)
Maximising
Sighted Years
Vision Related Quality of Life
Minimising
Visual impairment
Avoidable sight loss
ACCESS
To critical interventions
Timeliness

3. At the Coal Face… blind if not treated
Age-related Macular degeneration
Glaucoma
Diabetic
Retinopathy
Cataract

4. At the Coal Face… blind if not treated
Age-related Macular degeneration
Glaucoma
90% OF FOLLOW-UP IS FOR CONDITIONS
CAUSING IRREVERSIBLE BLINDNESS
Diabetic
Retinopathy
Cataract

6. PREVENT
UNINTENDED
CONSEQUENCE
e.g. stop RTT targets skewing clinical priority
TRUST
COLLEAGUES
TO CONTRIBUTE
e.g. WECS referrals
WECS postop review
Nurse clinics
Orthoptist injectors
TOP END OF LICENSE
e.g. Specialist leads
Consultant oversight
PAMs empowered
Technicians valued
EQUITY
No Post Code lotteries
Access based on need
Right person
Right place
Right time
EMPOWER PATIENTS
Respect as partners
Information
Education
Training
Support
Feedback

7. FOR TIMELY & EQUITABLE ACCESS TO CARE, CLINICALLY LED PRIORITISATION
PREVENT
UNINTENDED
CONSEQUENCE
e.g. stop RTT targets skewing clinical priority
TRUST
COLLEAGUES
TO CONTRIBUTE
e.g. WECS referrals
WECS postop review
Nurse clinics
Orthoptist injectors
FOR TIMELY & EQUITABLE ACCESS TO CARE,
CLINICALLY LED PRIORITISATION
GIVEN LIMITED CAPACITY
TOP END OF LICENSE
e.g. Specialist leads
Consultant oversight
PAMs empowered
Technicians valued
EQUITY
No Post Code lotteries
Access based on need
Right person
Right place
Right time
EMPOWER PATIENTS
Respect as partners
Information
Education
Training
Support
Feedback

8. Current Management of Ophthalmology System
Widespread deficit in capacity when compared with demand on services
Welsh Government’s close monitoring of new patient waiting times
Effect:
Excessively long waits for follow-up patients as a consequence of organisations prioritising new outpatients over follow-ups
c90% of follow-ups are at risk of irreversible harm
Compared with c10% of new referrals…
Remedy – Clinical Prioritisation

9. Clinical Prioritisation
New Measures project in BCU and ABMU West.
Patients no longer considered as new or follow-up, but categorised by their risk of irreversible sight loss/harm
P1,P2,P3 system – to allocate priority
& given evidence-based target date to be seen
New Measures project took place in BCU and ABMU (West) where patients are no longer categorised by new and follow up, routine and urgent but by 3 priorities according to their risk of irreversible harm and sight loss.

10. Clinical Prioritisation
P1 – Patients who may suffer serious irreversible harm from delayed appointments
P2 – Patients who may suffer reversible harm from delayed appointments
P3 – Patients who may be inconvenienced or suffer mild and/ or reversible consequences from delayed appointments

11. Priority versus Urgency
It is important to distinguish between priority and urgency as they are not necessarily linked.
Sending Flowers on Mothers’ Day = high priority, but if 6 months away then not urgent.
Speaking to your mum on the phone when she calls to thank you for the flowers is urgent but low priority if you are currently driving…
Resist the temptation to ‘carve out’ further with urgency categories within each priority group. A better strategy is to translate urgency into a factor that can be applied to all patients and then the queue remains intact but ordered by due date and urgency risk rather than separate queues. Here’s an example.....

12. Outcome Focussed Measures – Task and Finish Group
Chair – Dr Graham Shortland
Wide Representation –
WG, All clinician groups, Patients / 3rd Sector
Four Meetings + homework
Literature Review
Use of Welsh Examples – Ambulance Service

13. “New” Patient Target Date
Patients to have a new “Patient Target Date”
New and Existing (follow-up) Patients
Regular reporting of…
% of patients waiting over their agreed target date
Over-runs expressed as proportion of intended time
Details include clinical pathways involved

14. Process Measures Maximum waiting time following referral
Individual Target Date determined by clinical determination (National Condition Specific Guidance/Concensus)
Until the service is in balance this requires specific waiting time based on clinical need to define the risk if the Patient Target Date is missed
P1 – Risk of Irreversible Harm or Significant Patient Adverse Outcome if Patient Target Date is missed
P2 – Risk of Reversible Harm or Adverse Outcome
P3 – No risk of Significant Harm

15. Process Measures (contd)
E.g.
A P1 pathway can be any length, from weeks to months, depending on the condition and treatment requirements.
The “Purpose” of the priority code is to indicate the need to ensure that all patients are prioritised for the booking of their next appointment within the timelines specified, according to their need.
Reducing risk of harm from their condition

16. Timetable September Agree clinical timescales
October Implement Patient Target Date
October Ophthalmic Planned Care Board to inform Performance Measures
Roll-out across Wales

17. Any Questions ?