Lack of timely monitoring of patients with glaucoma

The RCOphth has been actively working with partners to deliver on the two recommendations requested from us to improve glaucoma care for patient. We believe the second recommendation should be completed over approximately the next couple of weeks, The first recommendation is progressing well but will come to conclusion under the National Outpatient Transformation joint work on eye care services. We do however have concerns about the two recommendations below, which are not directed at the RCOphth, which we believe are not progressing at the required pace for protection of patients. These actions are potentially straightforward to enact and would make an enormous impact on patient safety both for glaucoma and for other chronic eye conditions. However, despite efforts to liaise and regular pressure to progress the actions, these two require further action from NHSE and NHSD and any help to further progress this would be very welcome. Resolution of these are vital to efforts to streamline pathways, improve patient care and validate the results of the changes that national programmes and local initiatives are expected to produce. This will be benchmarking for trusts but ideally this should also be followed up with support for improvement projects to bring trusts back to compliance. They will also identify individual patients at risk for whom failsafe processes can be put into place to protect them from avoidable loss of sight. It is recommended that NHS England/Improvement commission NHS Digital to publish reports of hospital eye services’ compliance with the follow-up appointments performance standard included in the Portfolio of Indicators for Eye Health and Care. It is recommended that NHS Digital include provision for identifying, prioritising and monitoring patients at risk of developing sight loss within the next version of the national Commissioning Data Set. Provision should include the ability to record a risk rating and the recommended follow-up date for each patient, meaning these are mandated data items for collection by hospital eye services. This should be carried out in consultation with key stakeholders such as the Royal College of Ophthalmologists and patient administration system suppliers. We were planning to undertake this as the next phase for our Ophthalmic Workforce Group but instead this will now be delivered with as in partnership with other stakeholders including GIRFT and the College of Optometirsts as part of the National Outpatient Transformation Programme's Eye Care group, in conjunction with NHSE's Kate Branchett. We have already started the work on glaucoma pathways and this is planned to be supported by implementation tools and assessments of success. As part of the COVID lockdown and recover phase response, the RCOphth has already, and is continuing to, put out regular guidance on glaucoma provision that will help recovery of services but also lead to future transformation of glaucoma services. We are also working actively with NHS Trusts and Health Boards via the RCOphth clinical leads forum, as well as with optometrist and commissioners to ensure patients who need to be seen are seen during pandemic through improved and more optimal service reconfigurations which involve the whole eye care pathway. TIMELINE: TBC by NOPT.

The RCOphth and UKEGS the glaucoma specialist society have written and are about to jointly publish a new glaucoma risk stratification tool, Glauc-FAST Strat. We are just agreeing the final wording tweak between the two organisations and expect that to emerge in the next few weeks. We have also drafted together further document on how that relates to professionals, settings and qualifications to allow the risk stratification criteria to be easily translated into clinical practice across eye care services. TIMELINE: September 2020 Responses received on 23 July 2020.

We have made it a requirement, under the 2020/21 NHS Standard Contract, that every Clinical Commissioning Group (CCG) in England must agree an action plan on this recommendation with each of its local hospitals. The action plan will describe what the hospital will do, during 2020/21, to ensure that it complies fully with the Portfolio of Indicators for Eye Health and Care follow-up standard. The action plan, known technically as a “Service Development and Improvement Plan”, must be included as part of the local contract between the CCG and the hospital. The hospital must implement the actions set out in the plan during 2020/21, and the CCG will monitor implementation and ensure that improvements are made if progress is off track. Responding to the Covid-19 emergency is currently the top priority for the NHS at present, of course, but we will expect CCGs and hospitals to take forward the necessary actions on this recommendation as soon as possible. ACTION: NHS England / Improvement have included in the 2020/21 NHS Standard Contract a requirement for every Clinical Commissioning Group (CCG) to agree an action plan with each local provider of ophthalmology services, setting out what steps the provider will take during 2020/21 to ensure that it complies with the Portfolio of Indicators for Eye Health and Care follow- up performance standard. These plans (known as “Service Development and Improvement Plans” or SDIPs) will be included in each local contract. The provider must implement the actions set out in the SDIP during 2020/21, and the CCG will monitor implementation and ensure that improvements are made if progress is off track. Under the SDIP, the provider will be required to demonstrate that it is routinely: risk rating patients; recording a recommended follow-up date (by completing the Earliest Clinically Appropriate Date field in relevant outpatient datasets) NHS Digital and NECT guidance on PAS; reporting compliance with the Portfolio of Indicators for Eye Health and Care follow-up performance standard (95% of hospital appointments to be within no more than an additional 25% of their intended follow up period, including rescheduling of hospital initiated cancellations); and addressing full implementation of failsafe prioritisation processes for follow-up patients, as described in Elective Care High Impact Interventions: ophthalmology. Responding to the Covid-19 emergency is currently the top priority for the NHS at present, of course. During this period, contractual requirements on providers are being relaxed, and this will slow the progress on implementation of SDIPs. But we will expect CCGs and hospitals to take forward the necessary actions on this recommendation as soon as possible. TIMELINE: For inclusion in local contracts with effect from 1 April 2020 and for local implementation during 2020/21. Response received on 27 April 2020.

NHS Digital has taken forward this recommendation alongside the other recommendation HSIB directed at them in this report (Safety recommendation R/2020/063). NHS England and NHS Improvement does not commission NHS Digital to provide information in the portfolio of eye health indicators. NHS England and NHS Improvement understand that in 2020 NHS Digital established the plans and tactical requirements for changes to the ophthalmology datasets to address both these recommendations and data collection is expected to commence in April 2022. This response is for completeness in case NHS Digital’s formal response to you in respect to Safety recommendation R/2020/063 and any subsequent updates did not make that clear. Response received on 27 July 2021.

We agree that the way payment for ophthalmology appointments is made can adversely impact patients with glaucoma. To address this we are making both shorter- and longer-term improvements. In the short term, we intend to introduce a fixed payment for all outpatient attendances that will allow clinicians to make decisions about prioritising the patients that they see. As part of the NHS’s response to Covid-19, a set of extraordinary payment arrangements is currently in place instead of the usual payment system, the national tariff. So this fixed payment will be introduced in April 2021 in the next national tariff. We are also working closely with the Royal College of Ophthalmology and NHS colleagues to support their longer-term work reforming ophthalmology. Among other improvements, this work will improve data collection to support better payment design. Better-designed payments will allow the money to follow the patient across the boundary between primary and secondary care. In turn this will support Integrated Care Systems to better design ophthalmology services. We are planning to pilot this work in the next national tariff in April 2021 and scale it up nationally in subsequent years. ACTION: We will move ophthalmology outpatients onto a fixed payment to reduce the incentive to delay follow ups. TIMELINE: Planned for April 2020 but delayed because of the suspension of the 2020/21 national tariff as the NHS responds to covid-19. Will implement in April 2021. ACTION: Develop and pilot ‘pathway’ and ‘year of care’ payment models for ophthalmology. TIMELINE: Pilot from April 2021. Scale up nationally from April 2022. ACTION: Implement ‘year of care’ payment models for glaucoma. TIMELINE: April 2023. Response received on 24 July 2020.

We agree that a predictive risk stratification tool would be very valuable in glaucoma care in England and indeed across the UK. A tool that would rank patients according to the risk to their sight would help target resources to those who need it most, and ensure a consistent approach across Hospital Eye Services This would ease pressure on glaucoma clinics that are already full to overflowing, and are getting busier as the population ages and more people develop glaucoma. We are keen to support the development of a tool based on work already carried out in Bristol by Professor John Sparrow. We have indicated to Prof Sparrow that we agree in principle to support this research from our own charitable funds, pending agreement of the details of the research. The Royal College of Ophthalmologists in partnership with the UK & Eire Glaucoma Society (UKEGS, part of the IGA) will produce a joint document setting out risk stratification parameters which can be applied in all services, both those using paper based and electronic medical records (EMR). The next step will be to adopt the agreed thresholds and use them to produce EMR provider agnostic algorithms to allow for automation of risk stratification at a service level. Once developed, there will need to be a validation exercise where the automated stratification is checked manually against the original patient record to make sure that important issues are not being missed by the algorithm. This will be a fairly time intensive exercise, but our hope is that the work will be carried out in Bristol by Professor John Sparrow, and the IGA agrees in principle to fund this research, pending agreement of the details of the study. The reason for not proceeding directly to an automated electronic solution as recommended by the Report is that the majority of glaucoma services do not yet have the required electronic data for this to be useful across the board - hence the 2 stage approach. As services move to EMR systems, the electronic option will become increasingly useful, but this is expected to take quite some time as a move to electronic working for glaucoma involves back entry of significant amounts of clinical data. TIMELINE: TBA. The coronavirus emergency sadly means clinicians are focused on front-line medical care and much research is having to take a back seat. The IGA is able to respond as soon as researchers and clinicians time becomes available. Response received on 6 April 2020.