In January 2017 we carried out a consultation about where patients go for pre-operative and post-operative cataract appointments, in order to improve services for patients in the future.
More details about this consultation and the findings can be found below.
The previous system:
The proposed new system:
Who is doing this work and why?
NHS Liverpool Clinical Commissioning Group (CCG) is working with the local optical committee support unit, hospital eye services and community optometrists (opticians) to plan how to manage demand for eye services, whilst also improving care for the future and meeting new ways of working that are set nationally.
We are asking the public for their views to help inform a review of cataract services. This is to help us understand how the proposed changes would affect patients and to ensure any changes meet their needs.
The review focuses specifically on the initial cataracts assessment and post-operative care. It is proposed that these elements of the service are delivered in the community by opticians, rather than provided by hospitals.
What is a cataract?
A cataract is a clouding of the eye's natural lens, which lies behind the iris and the pupil. It can cause cloudy, blurry, or misty vision and affect one or both eyes.
The presence of cataract causes disability and increases the likelihood that individuals will suffer adverse events such as falls. It is the leading cause of blindness in the world. You can learn more about cataracts on the NHS Choices website here.
What is the service for cataract patients at the moment?
People who are diagnosed with cataracts usually start their journey with a visit to their high street optician, often because they suspect a problem with their eyesight, or because they think they need a new pair of glasses. A sight test is done at the opticians and it is here that the cataract is detected.
While a small number of opticians in Liverpool are accredited to perform an initial cataract assessment themselves under the existing scheme, in most cases a referral is made to NHS Liverpool CCG’s Choice Team. The Choice team will contact the patient, offer them a choice of hospital where they will go for a cataract assessment. If the patient is suitable for surgery then a pre-op assessment will be booked, following which surgery is scheduled.
However, following the initial assessment, some patients find they are not suitable for surgery or decided that they do not want to have surgery. This can be a long process that requires several different appointments.
How would the new service be different and how would it benefit patients?
Some opticians are accredited to provide initial cataract assessments under the enhanced Cataract Assessment Scheme. This means, they can ascertain a patient’s suitability for surgery and discussion the pros and cons of surgery. Then if patients wish they can make an onward referral for surgery. This removes the need for the patient to go their GP for a hospital referral, as the optician will perform the assessment and make the referral themselves.
If there’s time, the assessment is done at the time of the initial sight test, removing the need for the patient to return for another visit. If this is not possible then another appointment is booked. This way of working is designed to improve the patient experience by ensuring only patients who are suitable for and are willing to have surgery are referred to hospital services.
A total of 3,806 patients had a cataract procedures carried out during April 2015 – March 2016. Of these, only 362 patients had their cataract assessment performed by an optician. The proposal is to extend this approach so that all routine cataract assessments are carried out by opticians.
Where a patient has a known eye condition (such as Glaucoma), or there are other complications, the initial assessment will continue to take in hospital. In many cases these patients will already be under the care of hospital eye services, so the likelihood of them going to their optician with cataracts is limited.
Similarly, if your optician is not accredited to carry out the assessment you would be directed to NHS Liverpool CCG’s Choice team, who would offer you a choice of accredited opticians for you to book an assessment with.
Following assessment, the optician will send a referral to NHS Liverpool CCG’s Choice team, who will contact the patient to offer them a choice of hospital (Aintree or the Royal) for their cataract pre-op assessment and surgery.
We also want opticians to look after routine follow-up appointments wherever possible, rather than patients needing to go back to hospital, as happens currently.
In what circumstances would I need to go back to hospital after my cataract operation?
Figures from other parts of the country* suggest that around 80-90% of patients would only need to visit the hospital for their pre-operative assessment and cataract surgery under the new scheme. All other pre- and post-operative care would be done by opticians.
The redesign proposes that patients without complications post-surgery will be discharged on the day of surgery and will be instructed to visit their optician, should they choose to, after four weeks for their final post-op examination and eye test.
You would only need to go back to hospital if there were complications during or following surgery.
*the Royal College of Ophthalmologist Commissioning Guide suggests around 80% of cataract operations could potentially be followed up in the community. Data from the same service in Stockport suggests that over 90% of patients could have their follow-up appointments with their optician.
Why are these changes being considered?
This way of working is considered best practice in the 2015 commissioning guidance published by the Royal College of Ophthalmologists.
It is also supported by the Clinical Council for Eye Health Commissioning (CCEHC), which wrote to all Clinical Commissioning Groups in July 2016 to say that opticians should be the first port of call to manage and monitor cataract cases prior to referral to hospital.
The work we are doing aims to bring Liverpool’s cataract service in line with recommended guidance.
We also want to reduce waiting times for initial cataract assessments, reduce the number of unnecessary appointments people are asked to attend and to better manage the demand for this service.
By enabling opticians to provide the more straightforward care, hospitals will have more time to spend with patients who require more complex eye care.
What are the benefits for patients?
Waiting times for initial cataract assessments will be reduced and more routine care will be provided closer to people’s homes, with a greater choice of providers.
How will these changes be put into place?
The proposed redesign of cataract services will increase the number of initial cataract assessments available in the community by renewing and widening the accreditation scheme for opticians.
Each optician delivering the enhanced service will be required to undergo a defined training and accreditation process provided by Cardiff University and the Local Optical Committee Support Unit.
Opticians will also be required to attend a training session run by the Local Optical Committee, primarily to cover the administrative procedures and protocols involved in running the enhanced service.
While the specific number of opticians who will take part in the service is not known at this stage, early indications are the service is being well received by all involved in early discussions and a good spread of providers are expected to offer the service.
Under the existing scheme there are 16 opticians already providing the service, with a spread across most parts of the city.
We envisage that not all providers will take up the scheme, therefore arrangements will be put in place to arrange direct referrals to neighbouring opticians.
How much will this cost?
The scheme will be delivered within the current budget – it is not expected to cost any more than what we are providing at the moment.
There may even be small cost savings by moving appointments from hospitals to opticians.
Analysis by the Local Optical Committee Support Unit, who has implemented this scheme in many areas nationally, suggests NHS Liverpool CCG could save around £70,000 per year based on current figures.