Community eyecare services: review

Annex B: Enhanced Eyecare Services in Scotland

When the current eye examination service was developed in 2005, two levels of community eyecare were envisaged:

• Level 1 - the GOS Eye Examination
• Level 2 - services that require additional training by accredited optometrists e.g. treatment of common eye conditions, low vision services, co-management of chronic eye diseases such as glaucoma, macular degeneration etc.

There are a number of successful schemes that have been delivered under or in combination with GOS by individual health boards over a number of years. Most of these should have been delivered as level 2 services. These have not only resulted in patients being safely discharged from the hospital eye service into the community, but has resulted in costs being shifted from local to national budgets.

A number of these 'enhanced' services that are delivered across Scotland are set out below.

Lanarkshire Eye Health Network Service ( LENS):

The LENS scheme was introduced in Lanarkshire in 2010 with the purpose of attempting to reduce demand in the Ophthalmology Acute Eye Casualty Clinic. The scheme involves patients receiving treatment for a number of conditions and follow up appointments with their community optometrist, who have undergone robust training. This means patients can be seen in the community rather than being referred into secondary care. Patient satisfaction rates for the service have been high. Optometrists provide this service under the current GOS supplementary fee structure.

NHS Grampian

Eye Health Network

The walk-in service at Aberdeen's Eye Department was increasingly being used by the public for non-urgent eye problems. The level of walk-ins was at 6,000 annually and increasing, leading to long travel times and waits for patients, a chaotic environment, and specialist resources being used to treat non-urgent cases. An audit demonstrated that only 9% of patients coming to the eye department required referral to the hospital eye clinic; over 90% could have been treated within the community.

In response to this, in 2010, a clinical accord was agreed between GPs, ophthalmologists and optometrists to enable optometrists to undertake the management and treatment of patients with:

• Anterior Uveitis
• Herpes Simplex Keratitis
• Marginal keratitis
• Corneal foreign body which requires removal with a needle and/or an algerbrush.

To undertake this extra service, community optometrists have to undertake accredited training and following strict protocols. Following the introduction of this service, most patients are now managed in the community. Community optometrists receive an additional fee for carrying out these services.

Hospital Contact Lenses

There is a contract between a community optometrist and NHS Grampian to provide all complex lenses, therapeutic and cosmetic contact lenses. The Health Board funds the fitting, after care and supply of contact lenses and solutions

Glaucoma Tertiary Care

In 2004, a 'shared care' service for glaucoma was set up provided by accredited glaucoma optometrists ( AGOs). The aim was to reduce the number of unnecessary referrals to the hospital, to initiate treatment and prevent delays associated with secondary referral and monitor those at risk of developing glaucoma.

The Glaucoma consultant vets new glaucoma referrals to decide whether patients are seen by the AGOs or in the hospital glaucoma clinic. AGO's now diagnose, treat and manage patients with glaucoma depending on their level of experience, referring patients at higher risk of visual impairment to the hospital based service.

AGOs have an open line of communication with the glaucoma consultant to discuss any cases seen. They are expected to attend glaucoma-related postgraduate teaching sessions with the rest of the glaucoma team.

NHS Ayrshire & Arran

NHS Ayrshire and Arran currently run five additional optometry services. These are:

• Post-operative cataract assessment - patients who have received uncomplicated cataract surgery are assessed 4 weeks post-op by their local optometrist. This appointment is arranged prior to the patient being discharged from the Hospital Eye Service and helps to upskill optometrists. There are approximately 80 optometrists accredited to carry out this scheme.
• Low Vision Service - Optometry practices provide low vision assessments and aids to patients, funded by the NHS Board. These aids are funding entirely by the NHS Board.
• Hospital Contact Lens - complex fitting, therapeutic and cosmetic contact lenses are all fitted in the community
• Bridge To Vision - a service whereby optometrists promote and support patients with learning disabilities to access regular eye care. 18 optometry practices are currently involved in this scheme
• Diabetic Retinopathy Screening Service - optometrists undergo training to provide diabetic retinopathy screening in a community setting.
• Eye Care Ayrshire - a new scheme set to launch in October 2016. Optometrists will be promoted as the first port of call for all eye conditions, with all optometrists able to prescribe eye drops without the need to undergo independent prescribing training.

Optometrists receive an additional fee for providing each of these services.

In addition to these services, community optometrists also refer patients on a number of pathways, including smoking cessation and to local falls prevention teams.

NHS Tayside

In NHS Tayside, second eye cataract extraction patients are discharged after their operation into the community. Untreated ocular hypertension patients are discharged into the community. The Board has released guidelines on the discharge of treated ocular hypertension patients and some stable glaucoma patients.

NHS Fife

NHS Fife is progressing a shared care initiative via a 'test of change' with community optometrists for the treatment of patients with uveitis. Protocols have been shared from NHS Grampian where this initiative has been in place for several years. Optometrist's remuneration has been agreed locally.