How our evaluation defined future of eye clinic
Funding an independent evaluation of a community eye clinic has given a PBC consortium the knowledge it needs to secure the service’s future. Debbie Singh and Dr Nav Chana explain how
Funding an independent evaluation of a community eye clinic has given a PBC consortium the knowledge it needs to secure the service's future. Debbie Singh and Dr Nav Chana explain how.
In November 2007, a six-month pilot was launched of a new community eye clinic developed by a PBC consortium in Surrey – Integrated Primary Care Commissioning (IPCC), supported by Sutton and Merton PCT.
As part of the pilot, IPCC funded an independent evaluation, led by a researcher from the University of Birmingham.
Traditionally, evaluation of new services in primary care consists of a survey of patients who come into direct contact with the service, who usually give positive feedback about new provision unless you do something pretty horrible to them. IPCC wanted the evaluation to be as robust as possible within the timeframe and small budget available.
By sharing our experience, we hope to encourage other PBC groups to build evaluation into their business plans for fledgling services.
The need for the new service
The aim of IPCC's ophthalmology primary care clinic was to reduce the number of unnecessary referrals to secondary care. Every year GPs in Sutton and Merton refer more than 11,000 people to hospital ophthalmology departments. The Department of Health has suggested that such referrals could be assessed in a community setting.
In other areas of the country, diagnostic tests by consultant ophthalmologists in primary care have reduced referrals to hospital eye services by up to 23%.
During the pilot, the clinic ran for one morning per week from a GP's practice, and was staffed by a consultant ophthalmologist and an ophthalmology specialist nurse from the local acute trust, paid on a sessional basis. The clinic also had an administrator, supported by the practice manager.
Six practices, including the host practice, were invited to refer patients to the new clinic.
From the outset, IPCC knew it would be important to evaluate the service and commissioned an independent evaluation so that an expert could guide them through the process. The methodology comprised:
• collated data about referral rates and waiting times
• feedback from service users and staff
• a summary of cost savings
• a comparison with a group of patients visiting hospital eye care services.
The methodology was designed so that the clinic team could do the bulk of data collection, minimising any additional costs of evaluation. The clinic team used a spreadsheet to collect routine service use data, including referral and appointment dates and waiting times.
People who attended the clinic were given a feedback form after their appointment and asked to return it in a freepost envelope or to fill it in while at the clinic. Some 58 % of patients responded.
A comparison group from a different PBC cluster in a neighbouring area also received a feedback form, after attending traditional hospital eye care appointments; 42 forms were returned.
The clinic team took part in a short discussion to outline some of the key lessons learned.
All data were passed to the independent evaluator to collate.
The evaluation found:
• 227 referrals were made to the clinic over the six-month period
• cataracts and reduced vision were the main reasons for referral
• clinic triage of referrals resulted in 50% of patients being contacted to make a clinic appointment and the rest being referred immediately to hospital
• the clinic processed immediate referrals to hospital within one week
• 83 first referrals to hospital were saved by treating patients at the clinic or referring them back to their GP or optometrist
• at least 15 follow-up hospital appointments were also saved
• 80% of patients had a clinic appointment within three weeks of referral, compared with an average wait of more than a month among the comparison hospital group
• only 60% of patients in the hospital group were satisfied with the promptness of their appointment, compared with nearly all of the primary care clinic patients
• satisfaction with staff and the appointment booking process was also higher among clinic patients than the comparison group
• more than 80% of clinic patients said they would rather attend the GP clinic than visit hospital.
The key lessons learned were:
• using specialists in primary care can divert patients away from hospital
• the diversion rate of 37% exceeded the 25% potential suggested from the initial evidence review
• outside the host practice, not all practices were using the service to its full potential
• more hospital appointments need to be saved each month to meet a financial break-even point for the service within a shorter timeframe (see box below).
• developing strong relationships between primary and secondary care teams
• demonstrating the model of care works
• providing a service that is convenient and accessible to patients and with which patients are highly satisfied
• reducing referrals to hospital
• and educating GPs and optometrists informally and via letter about eye care and appropriate referrals to hospital.
During the pilot the clinic team learned:
• the importance of administrative support and involving administrators as key members of the team throughout
• the value of regular meetings between specialist teams and primary care hosts
• the importance of educating GPs and optometrists about the need for the service and undertaking widespread awareness- raising activities
• and the importance of feedback to improve quality of referrals.
The impact of the evaluation
During the pilot, data was collated so that an evaluation report was available immediately at the end of the pilot period. The evaluation report has been disseminated throughout the PCT and to interested parties.
If the service had been evaluated in the traditional way, it would have been able to demonstrate patient satisfaction.
But the comparative analysis has given the PBC group and PCT a much better idea of what needs to happen next to improve efficiency to meet break-even referral levels. IPCC had projected it would take about two years to break even, like any new business.
Since the pilot finished, the clinic has continued and expanded. It will now take referrals from all neighbouring practices in the PCT. An email and flier was sent out to all local practices and an awareness-raising event with optometrists is in the pipeline.
The PCT will launch a procurement exercise in September to select and approve a list of ‘willing providers' of community eye services.
The clinic's specification – on equipment, staff, and care – has been used in the PCT's procurement specification but IPCC will still have to compete with other potential providers to continue its service.
The total cost of the evaluation did not exceed £2,000. IPCC feels this was money well spent because the evaluation has secured the current continuation of the service.
To minimise costs while maintaining robustness, the evaluator designed the methodology and supported the clinic team to collect the data. All findings were then analysed and written up by the evaluator.
The evaluation was written up in a style that would be understandable and attractive to read, including telling the story through straightforward language, colour, graphics and photographs.
The clinic team said: ‘Most evaluation reports are so boring they are just thrown in the bin! We worked in partnership with the evaluator the whole way, to collect good quality information and present it in a user-friendly way. We were all part of the evaluation team – evaluation was not done "to" us, but with us and for us.'
Overall, the pilot and evaluation has shown that it is feasible to set up a specialist eye care service in primary care and reduce referrals, and work is continuing to demonstrate that it will also provide value for money.
Debbie Singh is an independent researcher and evaluator and also senior associate at the University of Birmingham Health Services Management Centre
Dr Nav Chana is a GP in Mitcham, Surrey, chair of the Integrated Primary Care Commissioning PBC consortium, and an executive member of the National Association of Primary Care Online
How our evaluation defined the future of our community eye clinic Dr Nav Chana, plus (left to right) ophthalmogy specialist nurse Lynn Ring; Anne Linnel, consultant ophthalmogist and clinic administrator Caroline Rodrigues Dr Nav Chana and team How the figures add up 60-second summary