The population of East Suffolk is largely elderly and rural. Glaucoma is a common problem and the group affected find it very difficult to get to the hospital. Not only is it a long way away but, with impaired vision, travel can be a real struggle.
We looked at the glaucoma work done at the hospital and found that, even for an annual review, patients were having to attend an average of 2.75 times to get through the necessary tests.
The main problem was that they couldn’t get on to the visual field machine – an important test that every glaucoma patient needs. Performing the test takes half an hour and there were often so many patients waiting for it that they had to go home and come back. DNA rates were high because these patients often became confused about appointments and had problems getting transport to bring them back another time.
We also found considerable variation in how often patients were reviewed. Patients who needed six-monthly review were sometimes not being seen for 15 months.
Because we had so many glaucoma patients – between 3,500 and 5,000 a year requiring review – they were being seen by whoever was available, including nurses, junior doctors and associate specialists. Sometimes it was necessary to recall patients to see more senior clinicians if someone was unsure what they were doing.
The private provider alternative
I had been trying to get a glaucoma scheme off the ground for 13 years and had got as far as designing a mobile clinic. But no one locally was interested in developing it. I then came across a scheme in Bristol that was doing the same thing, run by a company called Newmedica.
The Suffolk ‘i-van’ is a mobile clinic containing all the equipment needed to review the patients, including:
⦁ Visual acuity chart
⦁ Humphrey visual field test
⦁ Slit lamp
⦁ Goldmann applanation tonometer
⦁ Optical camera – fundus photography for optic disc imaging.
The i-van’s staff includes one whole-time-equivalent optometrist, two clinical assistants and one administrator who was locally recruited, employed and trained by Newmedica.
My preference would have been for this innovation and care to have come from within the NHS. But with busy day jobs we don’t have the capacity and it is difficult to persuade a trust that it can work de novo.
The incentive for the hospital provider to come up with this kind of concept does not exist as it is paid quite a lot of money to review glaucoma patients.
The i-van has been parked in Ipswich Hospital’s car park since the beginning of the year to facilitate data transfer at the start of the service.
The entire appointment in the i-van takes around an hour and no one leaves without having all the tests, so there is no need for them to re-attend until they are next due. The service can see up to 20 patients in one day.
Everything is recorded electronically and consultant ophthalmologists (who in our case are local but could be based anywhere) oversee the optometrists’ work using the web-based system. They can see all the retinal images and other results collected on the day. In addition, the Newmedica team digitises historical data from the hospital notes when a patient enters the service.
This is unusual, as most monitoring schemes are not overseen by a consultant in this way, yet we are finding that in up to 20% of cases the consultant makes changes to the optometrist’s suggested management.
On the move
We hope that, once we have done the initial work, the i-van will move out of the hospital car park. The service will have a fixed location in Ipswich, where around 60% of the patients are based, and will also travel to neighbouring towns and rural areas to cater for the remaining 40%. We hope to cover 5,000 patients within a 25-mile radius.
Ours is a primary care initiative and quite different from the way Newmedica contracts with acute trusts. Patients are still referred to the hospital for their first appointment by their GP or optician. The hospital consultants then deem who can have follow-up in the i-van. Savings are made on the reduced follow-up tariff and fewer visits. No new first appointment glaucoma cases are seen by the i-van team.
We estimate that around 80% of patients are stable and can be monitored in this way, but 20% are more complex and need the expertise of the hospital, which will have more time to help them in the way they need.
Acute hospitals are great at dealing with acute problems, but sometimes fall down on consistent chronic care. Hospital is not the best place for these patients to be managed. We should do this sort of thing elsewhere and leave the hospitals to do what they are good at.
We are paying a reduced percentage of the follow-up outpatient tariff (£67 for 2012/13) and £2.92 market forces factor, which is fixed for three years for each patient seen.
As well as this, there is a saving as the number of appointments is reduced because all tests are done in one go. Previously if a patient had to re-attend for the visual field check we were charged again. Of course, the mobile service is much easier and cheaper for the patients too.
Total savings in the first year will be around £500k. Over three years we expect to make total savings of £1.5m.
Some of the consultants are unhappy as they feel work has been taken away from them, but the lead clinician is supportive of the scheme and is doing some of the reviews.
The CCG/PCT has a contract with Newmedica to provide this service. Newmedica employs the optometrists and provides all the equipment.
The lorry is owned by Newmedica, but alterations have been made to our local specification and we have our own i-van name and graphic, along with CCG branding and the community glaucoma service livery on the side.
The consultants who review the optometrist’s work are paid for each review.
The number of elderly patients is increasing so the need for this service will escalate.
Originally we estimated 3,500 appointments would be needed but this is rapidly moving up to 5,000. It is a very easy service to replicate. The service is also able to see new patients if the commissioner wishes to extend glaucoma services further into the community.
Dr John Havard is locality group chair of Commissioning Ideals Alliance in East Suffolk, part of Ipswich and East Suffolk Clinical Commissioning Group
⦁ Initiative Community glaucoma review.
⦁ Start-up costs None locally as all included in agreed local price.
⦁ Staffing The van uses local skills, optometrist (core skill-based service), two clinical assistants, an administrator and consultant reviewers. Newmedica administration for management.
⦁ Savings Activity base 5,000. Annual savings against tariff are circa £35k + reduction from 2.759 appointments at national tariff to one appointment at local tariff, a fall from £664,125 to £206,325. Total saving for first year is circa £500k.
⦁ Outcomes Clinics see up to
20 patients a day. Normal patients are discharged, low-risk (50%) and stable (25%) are managed on six-month or annual intervals. A small percentage remain in the acute hospital. Consultant reviews take place within seven days. Patient feedback is positive. Waiting times are four weeks. Care is closer to home.
⦁ Contact john.havard@