Dr Paul Twomey describes a collaboration between primary and secondary care to improve the management of patients with eye problems in the community


The North East Lincolnshire GP specialist and teleophthalmology project was set up as a one-year pilot project in April 2001 by North East Lincolnshire PCT and the local acute trust Diana, Princess of Wales Hospital, Grimsby. The project is in line with the aims of the NHS Plan and is intended to create a ‘joined up’ approach by primary and secondary care to managing the demand on local ophthalmology services.

We planned to build on previous work, which had established a local care pathway for the management of cataracts, and to capitalise on developing partnerships across the local health community.

The project’s objectives were to reduce referrals to the acute trust ophthalmology service by developing local resources to manage more patients in the community. This involved:

  • Establishing a post for a GP specialist in ophthalmology.
  • Supporting designated opticians in managing patients.

Setting up the project

The PCT appointed a GP specialist with many years’ experience in ophthalmology. Three community opticians, based in Grimsby, Cleethorpes and Immingham, were selected to cover the entire PCT area.

The GP specialist and the opticians were each provided with a slit lamp and digital camera to assess the anterior eye and a hand-held fundus camera to take digital pictures of the retina.

It was anticipated that the GP specialist and the three opticians would manage the majority of patients. However, if the GPs and opticians needed further advice before deciding on appropriate management, digital images could be transmitted via a telelink to the ophthalmology department along with background information.

The ophthalmology consultants agreed to provide a report within 7 working days, to recommend one of the following courses of action:

  • Reassurance – no action required
  • Ongoing monitoring
  • GP treatment
  • Referral to the ophthalmology outpatient clinic for further assessment (with an indication of urgency).

However, referrals for urgent cases, e.g. suspected detached retina or acute iritis or those requiring assessment for possible cataract surgery or patients with squints, would continue to be made to the acute trust hospital, as before.

The GP specialist’s role

The GP specialist was based at a community clinic, seeing patients referred by other GPs for two sessions per week. He also continued to undertake sessions in the ophthalmology department at the acute trust.

The GP specialist’s sessions covered assessment, review and some ophthalmic minor surgery. Indications for referral to the GP specialist are given in Box 1, below. Figure 1 (below) shows the care pathway for patients seen by the GP specialist.

Box 1: Indications for referral to the GP specialist
  • Scarring/pigmentation of retina
  • Macular degeneration (indication for treatment)
  • Blocked tear ducts
  • Meibomian cyst
  • Recurrent blepharitis (not responding to standard treatment)
  • Persistent dry eyes (not responding to standard treatment)
  • Corneal opacities
  • Anisocoria (pupils of unequal size)
  • Retinoschisis review
  • Suspected diabetic retinopathy
  • Pterygium
  • Ectropion
  • Entropion
Figure 1: Care pathway for patients seen by the GP specialist

The opticians’ role

Local opticians already participated in the community diabetic retinopathy screening and monitoring programme. The three who were selected to participate in our project undertook further training to enable them to take a greater role in the retinopathy programme as well as to be able to assess patients presenting with other eye problems. Opticians’ assessments, including any telelink reports, were sent to the patients’ GPs in all cases requiring further action.

How successful was the service?

We have now had the opportunity to review the first 12 months of the project. The pre-determined outcome measures were:

  • Use of the service
  • Reduction in referrals to the acute trust
  • Patient satisfaction
  • Use of the telelink
  • Outcome of telelink referrals
  • Increased professional autonomy for designated opticians.

Use of the service

During the first 12 months there were 455 attendances at the GP specialist clinic – 346 new patients and 109 follow-up attendances. Some 165 minor surgical procedures were carried out.

The DNA rate was 4.6% and the cancellation rate 8.4%. We plan to investigate why patients cancelled or did not attend, to attempt to discover whether all referrals were appropriate. The waiting time for the GP specialist clinic is now approximately 5-6 weeks.

Of the patients seen by the GP specialist, 37 (approximately 10%) were referred to the ophthalmology department; this was around the anticipated follow-on referral rate.

A survey of GPs in the area has shown that most practices have used the scheme. There have been few referrals that do not follow the agreed care pathway.

Referrals

The GP specialist clinic has reduced the number of ophthalmology referrals to the acute trust. By September 2001, the number of GP referrals to the ophthalmology department totalled 101, or 8.2% below anticipated levels, while by March 2002 the number of GP referrals to the ophthalmology department totalled 200, or 6.8% below anticipated levels.

The initiative has supported the achievement of key performance indicators by the acute trust, with a reduction in the waiting times for a first outpatient appointment (Table 1, below).

Table 1: Waiting time for a first outpatient appointment
  31 March 2001 31 March 2002

Patients waiting >=26 weeks

Patients waiting 13 – 25 weeks

20

102

0

0

Work is being undertaken to see if there has been a reduction in referrals to the ophthalmology department for the types of eye problems assessed by the GP specialist. Initial data on the average number of follow-up appointments per first outpatient appointment has shown a rise from 3.21 in the year before the project began to 3.72 in 2001-2002. This appears to indicate that most referrals to the GP specialist are appropriate as such referrals are likely to be followed by few outpatient appointments.

Patient satisfaction

A survey of patients seen by the GP specialist and the opticians was carried out between January and May 2002. Some 63 patients were surveyed and 55 questionnaires were returned. Of those who responded, 80% rated the service ‘very good’; 84% said they were seen within an acceptable time; and 98% would be happy to use the service again.

Use of the telelink

There were some initial difficulties with the telelink, so it was in full use only in the second 6 months of the pilot. Security and confidentiality posed particular problems. NHSnet does not yet cover the three opticians taking part in the scheme so they used an ISDN line to send images and patient information separately using a unique reference, thus ensuring confidentiality.

The three cameras purchased for the scheme were the most appropriate available at the time the project was initiated. Disappointingly, some images transmitted for an opinion by the consultant ophthalmologist were not of good enough quality for effective assessment. We are considering how we can improve this aspect of the service.

Showing the images to patients has helped them to understand their condition better. In addition, archiving the images for reference has facilitated effective follow up of patients.

Developing the service

Overall, the project has had significant success in supporting the effective management of patients with ophthalmic pathology in a community setting. North East Lincolnshire PCT has agreed to support the development of the service and is discussing with the acute trust how to do so over the next 2 years, at which time there will be a further review.

To make the service sustainable in the short term and to achieve access for an opinion on a weekly basis, we intend to appoint a staff grade ophthalmologist to provide additional sessions working alongside the GP specialist in the community clinic. This will help to reduce waiting times as well as strengthen the links between primary and secondary care.

In the longer term, we also hope to attract other GPs to work as GP specialists in ophthalmology. The acute trust has offered to facilitate their professional development and support.

 

Guidelines in Practice, March 2003, Volume 6(3)
© 2003 MGP Ltd
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