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AT THE REQUEST of the Department of Health two proposals were developed within the health community, one led by East Devon PCT in partnership with the optical adviser and local optical committee and the other by the West of England Eye Unit (WEEU) within the Royal Devon and Exeter NHS Foundation Trust in partnership with the three PCTs. The East Devon PCT proposal included the innovative option of a mobile solution for patients who could not access the hospital eye service (HES) or the community option. The WEEU proposal had a wider scope as it was across all three PCTs that support the HES to move glaucoma follow-up patients from the HES to the community. When all parties found that there had been duplication, all agreed to support the successful proposal as the PCT executives and clinicians were enthusiastic. Glaucoma follow-up The East Devon proposal was successful with the proviso that the The East Devon PCT bid was given the go-ahead in May 2004 funding for the mobile solution was ring- to pilot a glaucoma follow-up scheme within a rural area, with fenced until a detailed ‘scoping exercise’ had been undertaken to assess the need particular emphasis on a mobile option. Nicky Lavender describes and value for money for this solution, and the issues particular to the East Devon pilot and describes how the an option appraisal paper prepared for review by the Department of Health. project has developed
PROJECT AIMS The aims of the pilot were to move so- DEMOGRAPHICS OF ACCESS This started a discussion on where we called ‘stable’ glaucoma follow-up patients should site the service, as East Devon has from hospital care to the community, The geography and demographics of East six community hospitals. We agreed that, under the care of appropriately skilled Devon PCT played a role in deciding the because it was a pilot site, we should pilot professionals, which in our case were desired proposal model, as the majority both models. One service would be sited community optometrists. This would, we of the population are based within seven in a community hospital but staffed by a hoped, provide the following: conurbations of which five are situated on community optometrist, and the other the coast with good road access. The A30 within a practice that could demonstrate ◆ Introduce a community eye care service runs through the PCT, but does not link a high standard of disability awareness and of specially glaucoma trained community with all coastal towns, so making planning access. optometrists distributed at population based on providing as equal access for the The final model was four locations but centres within optometrists’ premises whole PCT challenging. with a choice of sites, giving six locations throughout the East Devon community, To ensure that the locations of the as follows: providing a primary care setting with state service met local needs, the project GP of the art technology for glaucoma and representative asked all GPs to provide the ◆ Exmouth – Two community optome- ocular hypertensive follow-up care numbers of patients they had registered at trist practices ◆ Introduce a mobile eye care unit, their practice with a diagnosis of glaucoma. ◆ Sidmouth – One community optome- available to patients unable to travel to This information was then mapped across trist practice and Sidmouth Hospital the WEEU or community optometrists East Devon and the sites chosen to ensure ◆ Axminster – Axminster Hospital service, due to physical, mental, social, those areas with a population with highest ◆ Ottery St Mary – Ottery St Mary financial or other such hardship numbers of glaucoma patients had easy Hospital – due online in Jan/Feb 06. ◆ Establish a centralised glaucoma access to a location. register, for use by primary, community The second consideration was to Another issue was funding. Although the and secondary glaucoma care providers. enhance disability access; once we had funding for the project was adequate, made it easier for patients to travel to a to provide the ‘gold standard’ service as In reality, this meant that we were location, we did not want them to find they laid out in our proposal required a lot of increasing the capacity in the system, could not enter the premises. This had expensive equipment (Humphrey Field which would ensure patients were always been a criteria for service provision, Analyser, slit lamp with tonometer, HRT reviewed appropriately in a timely but community optometrists highlighted II and digital camera). We quickly came manner with easier access to the local that many of the local practices were in to the conclusion that we needed to community service. very old buildings and some with stairs. rationalise and the compromise reached
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was to choose a different community an algorithm was devised to ensure only OPTOMETRIST SUPERVISION hospital. This was not in the ideal location appropriate patients were referred to for access, but it was already partially this service. This was thought especially To ensure the clinical aspects of the equipped with ophthalmic equipment important as the clinical gold standard service were equal to that provided by because the HES had an out-patient clinic of glaucoma follow-up care was to be the HES, we built in regular clinical there. examined with a range of equipment to supervision opportunities, both via email determine whether the condition was and at the end of project meetings. This ‘stable’ or deteriorating. Unfortunately the has been further formalised in two ways, MOBILE SCOPING EXERCISE domiciliary service only uses two pieces of though both are only in the planning The next stage of the project was to equipment. Owing to the restrictions of stages. undertake the scoping exercise into the the patient’s disability and illness, it was Initially 50 per cent (reducing to 10 need for and the value for money of thought best to only see patients within per cent) of all patient notes of those who the mobile lorry. The original proposal this service who would not benefit from are not referred back to the HES will be had discussed using a vehicle equipped the ‘gold standard’. audited for both quality of documenta- with appropriate equipment that would tion against the protocol requirements drive around East Devon to patients who and clinical decision-making. In the first could not access either the HES or the PATIENTS’ VIEWS instance, one of the HES ophthalmic community service. One of the small risks to the project was registrars will undertake this. It is planned The scoping exercise was undertaken that patients would not wish to be seen that in due course it will become regular using the data from the GPs. When we by non-medical staff. To ensure that peer review by all participating in the had first asked for the numbers of patients patients were adequately informed of scheme. This review will include all with glaucoma, we also asked how many this development and offered the choice patient records seen within a glaucoma patients they had registered who were of location as well as gaining consent to shared-care scheme, including the HES wheelchair or bed bound. To collabo- transfer them to the community service, and that set up within Mid Devon PCT. rate this information we wrote out to all the HES wrote to all identified as meeting Secondly, we are planning to run residential and nursing homes asking for the parameters of the ‘glaucoma follow- bi-annually a clinical supervision and the same information. Both came up with up’ protocol, asking them to identify teaching session within the HES, run by very similar data of around 56 patients where they would like to be seen. They the HES. This will consist of all health- within the PCT. all chose the community service, giving care professionals involved in the shared Clinically it was agreed using the lorry strong indication that they thought this care glaucoma service across all PCTs, for this vulnerable frail client group was was a step in the right direction. examining and documenting four patient not an option. Firstly, they would find Anecdotal feedback from patients examinations. The ophthalmologist accessing a lorry, even if equipped with a via the participating optometrists in specialising in glaucoma then reviews the hydraulic lift, as difficult or impossible as both community hospitals and practices findings against the protocol. Feedback accessing the HES. Secondly, a lorry of was that they were delighted to be seen will be given both privately on a one-to- the size that would have been required on time – both for review and at their one basis, and common themes captured to ensure sufficient space for all the appointment time, and preferred being and presented back for open discussion to equipment required, would have found seen close to home. ensure common learning. visiting many of the patients in rural The next stage of the project is to more locations impossible because of narrow formally obtain patients’ views through and steep roads. Lastly, although the questionnaires and coffee mornings. PROJECT FACTS equipment is technically mobile, many This will enable us to substantiate the The project has seven trained optome- instruments require calibration and anecdotal evidence and use informa- trists, with four more commencing the effect of vibration on this delicate tion from patients to further develop our training, six sites in four locations within equipment was unknown. service around their needs. East Devon, and we are seeing on average It was proposed that we would set up a 60 patients per week with the number domiciliary service as it would enable us to increasing week on week. meet the limited need within the popula- SUCCESS FACTORS tion of patients who are bed bound, or for The enthusiasm of the initial seven whom accessing health care is difficult. community optometrists was a key THE FUTURE It would also release funds that could be benefit to the project. Fortunately, all The HES has already rolled out the reinvested into a sixth location – Ottery optometrists were prepared to work in all scheme to Mid Devon and Exeter PCT St Mary – thereby increasing access to the the required locations across East Devon using health professions, and wishes to whole service to ensure a fair, equitable and undertake domiciliary work. continue supporting and extending the service across the whole of East Devon. The willingness of the HES to take on service within East Devon to increase The domiciliary service would be the work of both training and supporting patient numbers to meet patient need. equipped with hand-held equipment in the new service has also added to its The HES will examine in the future the form of a Tonopen and ophthalmo- success. The HES has had the role of the possibility of developing glaucoma scope. We initially budgeted for a hand- offering advice to clinical questions and screening as well as follow-up in the held slit lamp as well, but two members of directing patients back to appropriate community. It is already looking to the project board were very experienced HES clinics. As the HES is working develop another Eye Care Services community optometrists who specialised without the electronic patient record, pathway – Low Vision and Rehabilita- in domiciliary practice. They pointed out the hospital staff have had to identify tion Service by working in partnership that through experience, if a patient was appropriate patients and photocopy all with community optometrists and social very infirm and bed bound, they would be the relevant notes. Optometrists are not services rehabilitation officers for the unable to use a hand-held slit lamp. at present linked to the IT network. The visually impaired. The domiciliary service began in HES is also unable to send patients’ notes September 2005. To ensure the service to a community optometric practice as ◆ Nicky Lavender is matron/service was not overwhelmed with referrals, as they need to be accessible at all times in manager, Royal Devon and Exeter many patients would prefer a home visit, case of an emergency. Hospital
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