National ophthalmology workstream: hospital eye services

1. Context, Issues and Vision

Ophthalmology is a high volume specialty dealing with patients with acute and chronic eye diseases and systemic diseases that may be sight or life threatening. The Hospital Eye Service ( HES) is currently facing a series of challenges; not least high levels of demand for new and return appointments and pressures arising from the growth of the ageing population and the development of successful new treatments. Recruitment and retention of all groups of the ophthalmology clinical workforce are proving difficult in order to keep up with this demand - and the forecast is for increasing need.

This is also a service where significant opportunities have been identified by the professions involved to use capacity and capabilities differently: opportunities for new models of care, opportunities for harnessing technology and opportunities for expanding staff roles and competences.

Furthermore, clinical advancement, new drugs, treatments and surgical developments have had a significant effect on this specialty; of note are the abilities to increasingly treat wet age-related macular degeneration and the growing number of people with glaucoma. The impact of demographic change with an ageing population and increasing patient expectations has resulted in greater actual and perceived need. Clinicians in the Hospital Eye Service have absorbed a significant increase in clinical activity already, with little additional investment, based on imaginative service developments and better use of technology. However, without more support it has become impossible to progress further and the ophthalmology community has requested assistance to support and expand novel ways to continue to provide safe, sustainable care for their patients.

Community Optometry services have become an integral part of primary care provision available to patients with eye conditions. There is a growing recognition that closer working between hospital and community eyecare services is desirable and inevitable. In addition to the work of this National Ophthalmology Workstream ( NOW), a Review of Community Eyecare Services is underway. It is the intention that outputs and recommendations will dovetail, within the context of the clinical strategy, such that maximum gains may be realised.

Significant changes in both clinical practice and the underlying systems and processes through which we manage patient services have already occurred. Further changes are needed in order to overcome the high demand for secondary care and there is a strong commitment and energy to do this.

National Ophthalmology Workstream

Established in 2014, at the request of the ophthalmology community in Scotland and supported by the Scottish Government, the programme built on earlier diagnostic work that focussed on shortfalls in capacity. This resulted in local 'Tests of Change' initiatives (see section 3), supported by the National Ophthalmology Workstream to develop and promote novel working practices as a basis for sharing and future development. The Workstream's focus is on learning and working together to reduce regional variation to influence the main drivers which support the national vision for a safe and sustainable service and to develop local approaches.

Since the start of the implementation phase in Summer 2014 detailed dialogue and peer review site visits have been carried out to all ophthalmology departments and Health Boards to explore exemplars and identify local barriers to change. The aim is to share best practices throughout NHSScotland and to reduce variation in practice. In addition there have been ongoing discussions with professional groups, including Eyecare Scotland, the Scottish Eyecare Group and Optometry Scotland, to identify a national perspective.

Such close collaboration with clinical and managerial colleagues enabled the development of 'What Good Looks Like' ( section 4.2). These have been articulated graphically across 6 keystone considerations. This has driven the promotion of best practices by streamlining pathways and processes across these areas, namely:

• Using data as intelligence for capacity planning;
• Booking processes to ensure that new and review patients are seen at the clinically appropriate time;
• A workforce that enables non-medical Health Care Professionals ( HCPs) to be upskilled using a needs and competency based model;
• Long term condition care using available intelligence and developing data sets for capacity planning;
• Higher volume elective surgery with better flow of patients through the system;
• Working across the primary/secondary care interface with high street optometrists to monitor and treat specific cohorts of stable patients.

Successful implementation of 'What Good Looks Like', depends on high level leadership and ownership, ensuring pace and profile in every Board, for maximum benefit. Health Board Chief Executives and Executive Leads play a key role in ensuring these opportunities are developed and firmly established in every organisation.

A National Symposium, held in Stirling, November 2015, enabled clinical and managerial staff working in HES and primary care to share and encourage further implementation of innovative ways of working. This was succeeded by a process of Peer Review Visits to each ophthalmology unit - this has proved a critical part of this process. Detailed and ongoing dialogue regarding challenges and solutions at all levels has been key for understanding and initiating change. This continues, with all those professionals who manage and deliver services playing a pivotal part. Common themes and recurring issues have been identified and, in particular, an enthusiasm to develop different ways of working has been continually identified and highlighted throughout.

Scoping work enabled each Board to identify specific areas on which they wish to concentrate, what benefits may be realised and how these can be prioritised. Much is dependent upon understanding the capacity available in Hospital Eye Service and how it could be developed to effect.

The workstream ( NOW) aims to consolidate and strengthen existing successful processes, to share new systems that have already been shown to work, and to systematically address any remaining, identified obstacles to progress.

As a result of this step by step approach the NOW has:

• Worked with HES to ensure clinically informed background work;
• Supported HES to develop 'tests of change';
• Shared outcomes of these at a national symposium;
• Undertaken series of departmental peer review visits which involved clinical and managerial stakeholders at all levels.

An Action framework was developed to include, local, regional and national solutions to highlight pressure areas and co-ordinate possible solutions - this framework is articulated graphically and can be found at appendix 1, its focus encapsulates:

• Local action plans within each Health Board;
• Regional solutions: by considering hub and spoke models for service delivery while being cognisant of consultant job plans and on call rotas to enable the delivery of complex treatments/surgeries;
• National solutions: highlighting pressure areas and co-ordinating possible solutions by supporting 'tests' of change' and implementing solutions to promote and embed, for example, training for optometrists, sub-specialty data capture and IT support.

Fundamental and key aims of this programme are to balance capacity with demand on a sustainable basis by:

• The use of robust data and information for capacity planning and management - using analysis and health intelligence as a basis for informed decision making - (a major finding of this workstream has been to recognise that current available information is inadequate for optimum effect and work has been commissioned to proactively develop and implement a solution-based approach for the HES);
  • Measuring activity, using updated datasets, and to make future planning realistic, streamlining supporting activities - this will inform booking processes and clinic templates;
• A clear national framework to promote a systematic approach, while recognising local needs through ophthalmology development plans and Health Boards' stated delivery priorities to reduce unwarranted variation and deliver standards of delivery that can be shared for transparency and overall benefit;
  • Sharing 'What Good Looks Like' across Scotland and embedding as common practice for the benefit of all patients, recognising in some circumstances the need for local variation;
• Practical support and partnership working to share and use models that are already being successfully employed to drive rapid improvement;
  • Reviewing the range of expanded roles performed by non-medical Health Care Professionals ( HCPs) in order to further enhance and extend these roles and responsibilities across the service- backed up by appropriate training and professional development;
  • Up-skilling the workforce to ensure that patients can be reviewed by the most appropriate professional relative to their condition;
  • Using technology - to enable different methods of delivering care by a multi-professional team;
  • Identifying novel pathways to deliver patient care and management both within secondary care and across the primary secondary care interface;
• Analysing the range of tasks and competencies in order to realign and enhance roles and responsibilities across the service - thus optimising the use of the multi-disciplinary team and developing ways to work more effectively both within the hospital sector and across the primary secondary interface recognising the need for training and professional development;
• Exploring the role of technology in the delivery of ophthalmic care.
  • Developing output measures in order to highlight where adaptation and adoption may be desirable - and to recognise where new developments are not performing against set metrics.