VISION 2020 UK 2nd Floor, 105 Judd Street, London WC1H 9NE 020 7874 1368 www.vision2020uk.org.uk

Dear Sir/Madam,

Impact assessment: 2017/18 and 2018/19 National Tariff Payment System consultation

VISION 2020 UK welcomes the philosophy of the proposals; specifically that setting a two-year tariff will give greater certainty against which to plan and make investment decisions and will reduce the burden on both commissioners and providers that comes from annual contract rounds. However we also believe that while setting a two year tariff is a good thing the proposed changes to the tariff for ophthalmology will compromise patient safety and patient outcomes; therefore VISION 2020 UK recommends that tariffs should not change.

VISION 2020 UK actively supports the increase in efficiency and integration within the NHS (as outlined in the 5 Year plan1) and is working on further integrated eye care between providers for the good of the patient/service user. This is shown in our ‘Quality standard for people with sight loss and dementia in an ophthalmology department’2 and the Ophthalmic Services Guidance, Eye Care for Adults with Learning Disabilities3.

We support the Clinical Council for Eye Health Commissioning’s (CCEHC): Primary Eye Care Framework for first contact care4 to reduce unnecessary referrals to the hospital eye service and a

1 https://www.england.nhs.uk/ourwork/futurenhs/nhs-five-year-forward-view-web- version/5yfv-exec-sum/ 2 http://www.vision2020uk.org.uk/quality-standard-people-sight-loss-dementia- ophthalmology-department/ 3 https://www.rcophth.ac.uk/wp-content/uploads/2015/09/Eye-Care-Services-for-Adults-with- Learning-Disabilities-2015.pdf 4 http://www.vision2020uk.org.uk/primary-eye-care-framework-for-first-contact-care/ ______VISION 2020 UK 2nd Floor, 105 Judd Street, London WC1H 9NE Reg. Company No. 7850769 Charity No. 1146746/SC046837 community ophthalmology framework to encourage more step- down care in the community.

We also support the CCEHC in saying a change in commissioning thinking is needed at supra-CCG and STP level combined with workforce development and an IT connectivity solution. We do not believe this can be done safely at the scale required within the timescale of this tariff document.

As already stated we are very concerned that the 30% transfer of follow-up costs into first attendances for ophthalmology at the expense of ophthalmology outpatient follow-up appointments is not a move to positively increase the quality of care for patients. Review patients are significantly more likely to have sight threatening pathology than new patients and cannot be discharged safely into the community. Furthermore, people likely to need follow up treatment in ophthalmology may be older people with age related sight problems (who could have comorbidities including dementia), or could be people with learning disabilities who are known to experience a higher prevalence of serious sight problems5. In cases such as these there are added risks that people will be 'lost to the system' if they are discharged into the community. The introduction of financial incentives for providers to undertake more first attendances at the expense of follow-ups will only exacerbate the current capacity pressures in the hospital eye service6.'

The Royal College of Ophthalmologists also highlights the delayed management of follow up patients7 due to a lack of capacity in the system which is exacerbated by the 18-week Referral to Treatment Time, this acts as a perverse incentive to see review patients. The unintended consequences of this change in tariff system will be similar and will act as a further lever for patient harm, unless time is given to train and develop an adequate primary care workforce that can deal with the needs of these patients.

5 https://www.seeability.org/who-we-are/media-centre/research/prevalence-of-visual- impairment 6 https://www.rcophth.ac.uk/2016/06/ccgs-urged-to-tackle-backlogs-at-nhs-england-eye- health-summit/ 7 ‘Surveillance of Sight Loss due to delay in ophthalmic review in the UK: Frequency, cause and outcome’ https://www.rcophth.ac.uk/standards-publicationsresearch/the-british- ophthalmological-surveillance-unit-bosu/abstract-surveillance-of-sight-lossdue-to-delay-in- ophthalmic-review-in-the-uk/ ______VISION 2020 UK 2nd Floor, 105 Judd Street, London WC1H 9NE Reg. Company No. 7850769 Charity No. 1146746/SC046837 VISION 2020 UK is committed to ensuring that patients and service users are offered a joined up and integrated service as outlined in the VISION 2020 UK ‘Adult Eye Health and Sight Loss Pathway’8 We also support the need for all patients to be treated in environments that are most convenient and most suited to their needs and by professionals with the appropriate skills and we are actively engaged in processes of developing a way forward to increase community capacity. This is outlined in the Royal College of Ophthalmologists ‘Competency Framework for expanded ophthalmic roles for Ophthalmic Nurses, Optometrists, Orthoptists and Ophthalmic Clinical Scientists.’9

We encourage the collection of data so that managers and clinicians can actively construct new care models and safe discharge policies.

We would welcome discussions with NHS Improvement alongside the CCEHC and the Royal College of Ophthalmologists as to how to best progress this agenda and ensuring that the current balance between tariff for new and follow-up appointments remains unchanged.

Yours Sincerely

Mercy Jeyasingham MBE

CEO VISION 2020 UK

VISION 2020 UK is the umbrella organisation which leads collaboration and co-operation between organisations with an interest in eye health and sight loss. For more information on VISON 2020 UK, please visit: http://www.vision2020uk.org.uk/

8 http://www.vision2020uk.org.uk/adult-uk-eye-health-and-sight-loss-pathway-revised- january-2015/ 9 https://www.rcophth.ac.uk/2016/01/competency-framework/ ______VISION 2020 UK 2nd Floor, 105 Judd Street, London WC1H 9NE Reg. Company No. 7850769 Charity No. 1146746/SC046837 VISION 2020 UK members are listed below:

Action for Blind People AHPO (Association of Health Professionals in Ophthalmology) Association of British Dispensing Opticians Association of Optometrists (AOP) Birdshot Uveitis Society Blind Children UK Blind Veterans UK (formerly St Dunstan’s) BlindAid (formerly Metropolitan Society for the Blind) British & Irish Orthoptic Society British Council for the Prevention of Blindness British Wireless for the Blind Fund College of Optometrists, The DAISY Consortium Deafblind UK Federation of Ophthalmic and Dispensing Opticians, The (FODO) Fight for Sight General Optical Council Guide Dogs Henshaws Society for Blind People International Glaucoma Association (IGA) Keratoconus Group, The Lions Clubs International MD105 LOCSU LOOK MACS – Microphthalmia, Anophthalmia & Coloboma Support Macular Society National Eye Research Centre National Federation of the Blind of the UK Nystagmus Network One Clear Vision Limited Partially Sighted Society, The Rehabilitation Workers Professional Network RNIB Royal College of Nursing Ophthalmic Nursing Forum, The Royal College of Ophthalmologists Royal London Society for Blind People RP Fighting Blindness (BRPS) SeeAbility Sense Thomas Pocklington Trust ______VISION 2020 UK 2nd Floor, 105 Judd Street, London WC1H 9NE Reg. Company No. 7850769 Charity No. 1146746/SC046837 Torch Trust VICTA: Visually Impaired Children Taking Action VIEW Visionary – linking local sight loss charities WESC Foundation Wilberforce Trust

VISION 2020: The Right to Sight is an initiative led in partnership by the World Health Organization, and the International Agency for Prevention of Blindness, for the elimination of avoidable blindness. http://www.iapb.org/vision-2020

______VISION 2020 UK 2nd Floor, 105 Judd Street, London WC1H 9NE Reg. Company No. 7850769 Charity No. 1146746/SC046837