Dr John Orchard describes a locality initiative from general practice which has vastly improved the waiting time and accuracy of referral of patients with cataract
The North Amber Valley locality commissioning project was one of the original 42 projects funded in October 1997. It consisted of 37 GPs in nine practices, based in the towns of Alfreton, Ripley and Crich. Situated on the northern border of Southern Derbyshire Health, the practices serve a population of 62 000, spread across three local authority boundaries.
Background to the project
Central to the scheme was local geography, taking the largest town of Ripley with its cottage hospital as the epicentre. The patients are equidistant (approximately 12 miles) from the nearest district general hospitals in Derby, Chesterfield and Mansfield.
As a result, the GPs have a long history of inter-practice cooperation to provide services at the cottage hospital, out-of-hours cover and postgraduate education meetings.
Of the nine practices in 1997, four were fundholders and five were non-fundholders. The fundholders brought to the group the experience of service developments within their own practices, and highlighted a two-tier system that existed at the time.
Discussion between the practices identified two major areas of concern: waiting time for operations, specifically for cataracts, and the ability of elderly patients to access services.
We resolved to address these concerns by maximising the use of existing facilities, bringing the services closer to the patients, and utilising the local optometrists in a more effective manner.
A unique opportunity had arisen with the appointment of a new ophthalmic surgeon at the Derbyshire Royal Infirmary, with a brief to develop outreach services.
The cottage hospital at Ripley had never had an ophthalmic service, but negotiations between the community trust, the locality commissioning group and the health authority led to the establishment of an out-reach clinic for ophthalmic services at Ripley Cottage Hospital for the North Amber Valley GPs.
Discussions within primary and secondary care identified an unacceptable waiting time of 18 months to 2 years for cataract referral patients to undergo surgery. Most of the delay was caused by patients being referred for cataract operations as soon as an optometrist reported the presence of a cataract, regardless of any other factors.
We decided to devise a protocol that would identify those patients most in need. To this end a protocol was designed using similar principles to those used previously for implementation of a referral protocol for large joint replacements (see Guidelines in Practice, October 1999).
Key elements of the scheme were as follows:
- Access to the clinic for cataract operations was to be limited to members of North Amber Valley locality commissioning group. This was important because practices not belonging to the scheme also used the services at Ripley Cottage Hospital, although they were not to have access to the ophthalmic clinic.
- No referrals for cataract surgery would be accepted unless they were accompanied by a correctly completed protocol.
- Patient assessment would be under-taken primarily in primary care.
- Patients would be admitted to hospital following a single outpatient appointment with the consultant, thus reducing the number of outpatient attendances.
- Preoperative and postoperative clinic attendance would take place at the cottage hospital and not at the district general hospital.
Before referral, all patients would:
- Have their cataracts assessed by the GP.
- Wherever possible, have their visual acuity accurately determined by an optometrist.
- Undergo assessment, which would consist of a score for visual acuity. A patient with >6/9 visual acuity in either eye would not qualify for referral, but a patient with visual acuity <6/9 who wished to drive, or one with visual acuity <6/12 in either eye, would qualify for referral.
- Be assessed for coexisting eye disease. Those found to have coexisting eye disease would not be deemed suitable for automatic inclusion in the protocol.
- Be assessed for social functioning: a patient who was resident in part three accommodation would have less priority than someone living independently alone.
- Be assessed for physical health and have a simple eye examination performed to establish that the cataract was present.
On the basis of these assessments, patients were given a score as indicated in the cataract referral protocol (Figure 1,below). Those scoring 8 or more out of 10 were deemed suitable for referral.
|Figure 1: Cataract referral protocol|
During the first year after the introduction of the protocol, the strike rate (the number of patients deemed suitable for surgery following referral) rose from 75% to 95%.
The reason why 100% of patients were not deemed fit for surgery is that several patients did not realise that cataract operations would involve surgery. The protocol was subsequently amended to ensure that it was made clear to patients that they would undergo surgery.
The patients identified for surgery from North Amber Valley were booked into a specific operating list and operated on within 6 months fromKtheir outpatient referral. They were all operated on from a single list.
As transport was a major factor for elderly patients, it was arranged for them all to be picked up on the same day and delivered home by the same vehicle. This led to the outing taking on a coach trip type atmosphere.
This grouping of patients was also an advantage when planning postoperative care, which took place at Ripley Cottage Hospital and, where necessary, any nursing care to be given by the district nurse.
First, the protocol was altered so that patients understood that they would undergo surgery.
Second, it was realised that this protocol represented a duplication of effort. Most patients initially consulted an optometrist with their visual problems. The optometrist was obliged under his terms of service to fill in a GOS18 and refer the patient to the GP in order that any patient found to have a cataract could be referred on for surgery.
It was also apparent that a number of other referrals from optometrists to GPs were a similar waste of time, in particular the necessity to be referred for registration of visual impairment, which has to be done by a consultant ophthalmologist, and does not require any input from a GP.
It was therefore decided to combine the referrals into a form that could be used in triplicate by the optometrist to refer patients directly to the ophthalmologist (see Figure 2, below), cutting out the need for the GP to see the patient.
|Figure 2: Cataract examination record and referral form|
The form was processed, arranged in triplicate and distributed to a number of optometrists within North Amber Valley. The form has a section where the GP is able to veto the referral if necessary. Apart from that, the referral is made directly by the optometrist. This development has many advantages:
- Patients only have to visit one healthcare professional.
- The healthcare professional they see is the one most skilled in making an adequate assessment of the patient's needs.
- The parameters for referral are clearly defined and patients whose visual acuity is not significantly impaired will not be deemed suitable for a surgical procedure.
- The GPs' time is saved as they are not seeing people to whom they have only minimal clinical input.
- The protocol has now been rolled out across Southern Derbyshire, as the Southern Derbyshire Action on Cataracts. This has been successful in gaining financial support for the development of the entire scheme.
The referral form for optometrists was introduced in November 2000. The strike rate for optometrists using this form so far is 100%. Although this represents only 20 patients, it is nevertheless a commendable result.
This scheme, which has vastly improved the waiting time and accuracy of referral of patients with cataracts, not to mention the convenience of them only having to approach one healthcare professional before referral, has clearly demonstrated that initiatives from general practice can significantly improve the quality of care provided to patients.
When considered in conjunction with the very significant gains achieved for patients using the large joint referral protocol, it can be seen that the care of patients within a locality can be significantly advanced by the cooperation of primary and secondary care, provided that the individuals in each of those organisations are willing to move sufficiently to enable a change of custom and practice to occur.
We have also demonstrated that involvement of the professions allied to medicine, in this case optometrists, and in the case of the large joint replacement referral protocol, physiotherapists, is of great benefit to all.
If you have a practice or locality initiative that you would like to share with readers, please contact us by:
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