How GPs set up a community opthalmology pathway

Dr Hyunick Kim explains how he helped spearhead a redesign of ophthalmology services in South West London

Setting up a community ophthalmology pathway

One is often led to believe that changes are only brought about by leaders of organisations and that it requires some intangible leadership qualities. One of the privileges of being a fellow in clinical leadership and management was learning that leadership can come from anywhere and anyone can be a change agent if one is willing to step up. Burke (1987) stated that successful change agents need to be able to tolerate ambiguity, posses good conceptual skills and have self confidence and self direction. Ulrich (1997) also emphasised the importance of soft skills such as good communication skills to convey the vision of change and build good relationships with stakeholders. The same qualities a good GP would employ in their everyday work. As part of the fellowship, I was tasked to lead a change management project with support from the PEC chair at NHS Richmond. The project involved redesigning and setting up a community ophthalmology pathway.

Process mapping

The most useful technique I found in the project was ‘process mapping' as it allowed him to address several issues with one tool. The tool was used to identify deficiencies in the system in the planning stage, to visualise the proposed new ways of working, and to communicate and engage with stakeholders in the implementation phase. Plsek (1999) argued that taking a process view is one of the key characteristics of organisations who are successful in improvement, along with adopting evidence-based practice, learning collaboratively and being ready and able to accept change.

There are two stages involved in process mapping. First, is to build up a complete picture of the patient's journey. Second stage involves examining the map to determine where there are problems such as duplication, parts of the process that are unnecessary or do not add value, and where bottlenecks occur.

Community ophthalmology pathway

In the ophthalmology redesign project, I first engaged with various stakeholders to agree the overall objectives of the change management project and to gain a better understanding of the patient pathway. This involved talking to local GPs, GPs with specialist interest in ophthalmology, PCT managers, patient representative groups (LINK), local optometrist committee and gathering information from other PCTs who underwent similar redesign projects. The challenge of conducting process mapping in the community care setting was that it was unrealistic and difficult to get all the stakeholders in one place together to participate in the mapping exercise. As a result, the exercise was spread out across time and the author had to play a more active role in constructing the patient journey and re-presenting the information back to the stakeholders. Although the process took longer than expected and in incremental stages, the advantage of maintaining constant communication was that I was able to build a relationship with the various stakeholders and gain agreement on the broad objectives of the service redesign that would suit everyone across the group.

The agreed objectives were to:

•Increase patient access

•Increase patient choice

•Reduce patient journey

•Reduce unnecessary referrals

•Improve value for money

•To ensure patients are seen in accordance to NICE guidelines (best practice) where appropriate

To meet the objectives of increasing patient access and choice, an Any Willing Provider (AWP) approach was taken on contract negotiations with ophthalmology care providers, rather than a tendering process, so that the new clinic would run along side existing services. It was envisaged that the increased competition to the local market would raise standards and reduce complacency that had set in with monopoly providers.

By providing additional competition of eye care providers, the commissioners were able to negotiate a reduced price on hospital tariffs for ophthalmology care. This was in addition to agreeing a local enhanced service agreement with the local optometrists to provide repeat eye pressure measurements. Studies showed that by providing repeat eye measurements, up to 60% of unnecessary referrals to the hospital can be avoided, saving the trust an enormous amount of money on new referral fees. It was also argued that this would be better for patients, as they can avoid unnecessary anxiety and trips to the hospital.

To reduce steps in the overall patient journey, it was also agreed that GPs did not add value to the process and served to be a source of delay of referral. As a result, it was proposed that the GPs would be taken out of pathway and allow optometrists who are the first point of contact for patients to refer directly into the ophthalmology services if necessary for a small fee. GPs would still receive a copy of the referral letters as overall patient care responsibility still remained with the GPs. The GP community fed back that they were happy with the changes as this meant less administrative burden for them as well.

Once these changes were made, the flow diagrams from the process mapping exercise became useful visual tools when re-engaging with stakeholders and outlining the new vision of working. *See attached file to the right for a simplified diagram used in process mapping of the original patient journey (fig 1) and the newly designed pathway for comparison (fig 2).

Reflections

Looking back on the success of setting up the new pathway, one of the lessons was realising the importance of data. The most difficult part of process mapping was obtaining and understanding what happens to patients at different points in their journey, especially when attending hospitals. Hospital episode statistics (HES) was too inaccurate to validate the exact activities that took place in secondary care. The lack of information and poor discharge letters from hospitals were one of the main complaints from local GPs as well. To address these concerns and to ensure better performance management, electronic records and template letters were stipulated for use in the community clinics to allow better and more relevant data collection. Increasing societal pressures for transparency and accountability will no doubt increase the need for better data collection.

Another lesson was discovering the benefits of collaborative working between managers and clinicians. The service redesign project would not have been able to be implemented without the support of enthusiastic managers willing to make the business case for the changes, along side the clinical case. Evidence from past successful change projects show that major change is rarely dependent on the actions of lone individuals and highlights the value of harnessing the skills and experience of those around you.

Summary

In summary, the main lessons for the future would be to engage with stakeholders early on to address their concerns and expectations. Ensure good communication using a variety of formats to guide and support the change process. To use clinical evidence to strengthen your argument and overcome initial scepticism and to be clear about the objectives one hopes to achieve. And lastly, to recognise the benefits of collaborative working and work closely with managers and other important stakeholders who are able to help implement the changes you hope to achieve.

Dr. Hyunick Kim is a GP clinical leadership and management fellow at NHS Richmond