Cataract Business Case (rev Nov 2013)

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LOCSU Community Services
Outline Business Case – Service
Development
Cataract Referral and Post-Operative
Examination
Issued by
Local Optical Committee Support Unit
August 2009
[Revised November 2013]
Outline Business Case – Service Development
Title of Proposal:
Cataract Referral and Post-Operative Examination
Author Name and Role:
Name & role of person who will
CCG Chair sponsor support agreed:
present to the Commissioning
Decision Panel:
Date of proposal:
Proposing Organisation(s) &
Proposed Provider Organisation(s):
constitution:
[Insert key contact details]
Executive summary
This proposal is to pilot a Community-based pre- and post-operative care of cataract
patients, eliminating the requirement for a visit to a GP, providing a comparable service for
patients who are unable to leave their home unaccompanied but who are able to attend
for surgery.
The proposal supports the national and local strategic priorities of providing care closer to
home by moving appropriate work from secondary to primary care settings; evidence
based practice and providing patient choice. It also supports the CCG’s QIPP Plan by
reducing costs and introducing innovative practice.
A recent audit in Stockport1 found that the proportion of patients listed for surgery
following referral had risen from 62% to 86% which meant a reduction in unnecessary
hospital referrals.
Patients can be referred to the service by their GP or Optometrist, or they can self refer.
The assessment will be undertaken by a number of accredited optometrists within suitably
equipped premises locally. Savings of around [insert number] per 1,000 referrals can be
achieved.
1
Stockport Cataract Audit 2011. Trevor Warburton
LOCSU Cataract Business Case.
Copyright © LOC Central Support Unit. Aug 2009. All Rights Reserved. [Rev Nov 2013].
Page 2 of 15
1. Description and purpose
This proposal is to set up and evaluate a community based Pre- and Post-Operative
Cataract Service in [insert name of CCG] for 2 years.
The proposal supports the strategic and operational drivers of [insert name of CCG] as
defined in [insert name of document(s)] for this CCG – e.g. Commissioning Strategy Plan;
Eye Care Strategy; QIPP Plan]. It is estimated that the service will save about £ [insert
number] pa across the area.
The aim of the service is to improve eye health and reduce inequalities by providing access
to eye care in the community and reducing the number of visits post surgery to the
Hospital Eye Service for patients in [insert name of CCG].
2. Strategic fit and QIPP [reference national and local documents where possible]
This proposal supports the following national and local strategic priorities:

Providing care closer to home

Moving appropriate work from secondary to primary care settings

Evidence based practice

Providing patient choice

Setting up integrated pathways
It also supports the CCG’s QIPP Plan:

Improving efficiency and reducing costs

Improving clinical quality and outcomes

Introducing innovative practice
3. The current position
Currently due to the constraints of a General Ophthalmic Services (GOS) sight test,
optometrists refer all cases of cataract to secondary care for confirmation of the diagnosis
and treatment where necessary. This works well when the diagnosis is positive and the
patient wishes to undergo surgery. However, there is no provision for counselling patients
on the risks and benefits of surgery or investigating possible contraindications to surgery.
LOCSU Cataract Business Case.
Copyright © LOC Central Support Unit. Aug 2009. All Rights Reserved. [Rev Nov 2013].
Page 3 of 15
This is unnecessary. The current pathway puts inappropriate clinical work and unnecessary
pressure on the local hospital. It is inconvenient for patients. It does not allow for a
proper, informed referral. It wastes resources.
4. Our proposal
Local needs
Estimated number of patients the service is likely to cover: [insert number].
Data from the National Eye Health Epidemiological model predicts the following for
cataract prevalence across [insert name of CCG].
Low Estimate
[insert number]
High Estimate
[insert number]
Mean
[insert number]
Applying evaluations of Cataract services elsewhere to the CCG’s analysis of need/our
analysis of the CCG population and referral rates [delete as appropriate], we would
estimate that [insert number] people would use this service each year, plus or minus 5%.
Evidence of best practice
In England, an audit of the Stockport cataract referral pathway found that the proportion
of patients listed for surgery following referral has risen from 62% to 86% reducing
unnecessary hospital referrals. [Insert as appropriate]
The pathway
A GOS sight test will reveal the presence of cataract and the optometrist will discuss this
with the patient. If the cataract is not presenting any significant visual or lifestyle
difficulties then the patient will continue to be reviewed by the optometrist. If the patient
does wish to be considered for surgery then the optometrist will provide a self assessment
questionnaire which will help to establish suitability for surgery highlighting other health
problems and possible contra-indications. The patient will attend for the full cataract
assessment to elicit relevant ocular, medical and social information which will assist the
HES to ensure patients receive the most appropriate treatment and care. If the patient is
willing to undergo surgery and the optometrist considers that they are suitable, then the
referral form will be completed and the optometrist will provide the patient with the
choice of treatment centres and fax or post the referral and self-assessment questionnaire
to the centre.
LOCSU Cataract Business Case.
Copyright © LOC Central Support Unit. Aug 2009. All Rights Reserved. [Rev Nov 2013].
Page 4 of 15
The post-operative service provides for the assessment and management of patients who
have now undergone the cataract surgery in either eye. Patients without complications
post surgery will be instructed to visit the referring optometrist after 4 weeks for the final
post op examination and GOS refraction. If the patient is happy and the vision is good the
optometrist will complete the report form and send copies to the GP and treatment centre
and will discharge the patient.
Clinical governance and patient satisfaction
Levels 1 and 2 of the ‘Quality in Optometry’ (Appendix 3) clinical governance toolkit will be
the benchmark used and the contractor must adhere to the core standards, as set out in
the toolkit and be able to provide evidence of this to the CCG if requested to do so.
Each practitioner providing this community service will first undergo a distance learning
training and accreditation process defined by LOCSU and provided by Cardiff University.
Practitioners wanting to participate in the service will also be required to attend a training
session run by the LOC and CCG, primarily to cover the administrative procedures and
protocols involved in running the community service.
Practitioners will follow all relevant CCG policies and procedures as required – to include
patient complaints, serious untoward incidents and clinical audit.
In particular, the provider will investigate and respond to any complaint made about their
provision of service initially in accordance with their mandatory/additional services
contract complaints process and in accordance with NHS Patients’ Complaints Regulations.
National Health Service (complaints) regulations 2004, No. 1768 and National Health
Service (complaints) amended regulations, 2006, No. 2084 and “Safeguarding Patients”
2007.
The benefits2 of the service are as follows:
For the patient
2

Access to appropriate eye care in local service

Less travel time, time off work and related costs (for patients or their carers)

More time for questions and answers
Sheen NJL, Fone D, Phillip CJ, Sparrow JM, Pointer JS and Wild JM. Novel optometrist-led all Wales primary eye-care services:
evaluation of a prospective case series. BJ Ophthal. 2009
LOCSU Cataract Business Case.
Copyright © LOC Central Support Unit. Aug 2009. All Rights Reserved. [Rev Nov 2013].
Page 5 of 15
For the commissioners

Reduced inappropriate use of secondary care

Recurrent savings (estimated at £[insert number] pa)

Care closer to home in a convenient community setting

Patients offered a choice of providers
For the GP

Simple referral administration

Comprehensive reporting for GP about their patient
For the HES and ophthalmologists

Fewer inappropriate referrals

Improved communication between primary and secondary care
5. Activity and financial analysis
Assumptions re the existing pathway:
1. All patients with signs/and or symptoms with cataract are currently referred to
secondary care
2. 65% of cataract referrals proceed to surgery and all patients who have surgery have
2 follow up appointments
Assumptions re the new pathway:
1. 70% of patients who have primary care referral refinement for cataract will be
referred to secondary care
2. 93% of those referred will proceed to surgery
3. All patients who have surgery will have one post op check in primary care in the
new service
IT admin costs of £10 per patient have been included assuming that LOCSU approved
software is used to capture the clinical data, provide reports on activity and outcomes
and produce invoicing.
LOCSU Cataract Business Case.
Copyright © LOC Central Support Unit. Aug 2009. All Rights Reserved. [Rev Nov 2013].
Page 6 of 15
Potential savings per 1,000 referrals
£
Current service
1,000 secondary care initial appointments (£112.00)
1,300 secondary care follow ups (£65.00)
Total
112,000
84,500
196,500
New service
1000 community cataract assessments (£53) plus £10 admin fee
63,000
700 secondary care initial appointments (£112.00)
78,400
650 community cataract follow ups (£34.50)
22,425
Total
Saving
163,825
32,675
Cost of new service in primary care is £163,825 therefore an overall saving of £32,675
per 1000 can be predicted.
6. Implementation
In preparation for implementing this proposal, we have:




Developed the new national pathway
Identified the local optometrists who would like to participate in the service
Prepared accredited training packages
Surveyed local premises to ensure suitability and availability of equipment
Full implementation
Full implementation will take three months from the date of approval in order to:



Adapt the national pathway to local conditions in discussion with
ophthalmologists and commissioners
Deliver training and ensure accreditation
Develop communication plan and materials for the Hospital Eye Service, patients
and the public
LOCSU Cataract Business Case.
Copyright © LOC Central Support Unit. Aug 2009. All Rights Reserved. [Rev Nov 2013].
Page 7 of 15
7. Risk analysis and mitigations table
Risk
Mitigation
Clinical Risk 1: Post – operative
The service is designed to utilise the core
complications and are missed by the
competencies and skills of optometrists. To ensure
optometrist
consistent, high standards among providers,
optometrists will undergo a nationally defined
training and accreditation process provided by Cardiff
University
Financial Risk 1: GPs may continue to
A communications plan targeted at GPs will ensure
refer to the HES if they are not aware of
that the scheme receives maximum publicity during
the service, resulting in a reduction in
implementation and periodically thereafter.
savings compared to those predicted
Other Risk 1: HES may not support the
The LOC will work closely with the HES to ensure that
proposal
all concerns are addressed.
The HES will be part of a quarterly audit and review in
the first year of operation so that any problems can
be addressed as they emerge
Other Risk 2: Patients prefer to attend
The pre and post cataract service supports a seamless
the HES rather than an Optometric
integration between primary and secondary care,
practice for post-op check.
moving services closer to home for the patient and
utilising the skills of optometrists within a community
setting. Studies have shown that patients prefer to
have their care managed closer to home.
8. Contractual matters
The service will utilise the OptoServ IT solution developed by LOCSU and Webstar Health
for this national pathway. The OptoServ software automatically generates secure activity
and outcomes reports, robust audit data, and referrals and invoices, facilitating
performance management of the community services and eliminating the need for any
manual data processing.
LOCSU Cataract Business Case.
Copyright © LOC Central Support Unit. Aug 2009. All Rights Reserved. [Rev Nov 2013].
Page 8 of 15
We offer two models for contract management:
Contracts with individual General Ophthalmic Services Providers
The CCG can commission the service directly from participating community General
Ophthalmic Service contractors as a locally enhanced/community service. Under
this model, the CCG will be responsible for paying and performance monitoring
contractors on an individual basis.
Contract with LOC Single Provider Company
The CCG can commission the service from the LOC Single Provider Company.
Under the second model, (detailed in Appendix 5) the LOC company would provide
a fully coordinated and managed service, including payment disbursement to
providers.
We will provide a single point of contact for all matters associated with the service. We
will use the CCG’s standard contractual documents and procedures. This will include
mandatory data provision and a remedial period for any performance problems.
We would propose that the service is commissioned for two years in the first instance to
allow it to become established and fully evaluated.
We would also propose quarterly performance monitoring meetings with the CCG’s
nominated eye care lead manager and clinician in year one to gain the necessary
assurance, then, subject to performance, move to an annual review with meetings only by
exception.
In Appendix 2, we have suggested a performance monitoring data set, covering activity,
clinical, quality and financial matters for the CCG to consider. We would propose that this
is submitted to the CCG on a monthly/quarterly basis in arrears, within two weeks of the
end of the period. An invoice for the service provided will be submitted at the same time
to enable easy reconciliation.
Signed
Chair, [insert name] Local Optical Committee
Date
LOCSU Cataract Business Case.
Copyright © LOC Central Support Unit. Aug 2009. All Rights Reserved. [Rev Nov 2013].
Page 9 of 15
Appendix 1
Detailed Description of Service
Patients can self-refer into the service or be referred by their own GP or optometrist.
There is a list of participating optometrists for the patient to choose from.
The criteria for inclusion of patients will be any patient with signs and/or symptoms of
cataract in either eye.
Special requirements – equipment
All practices contracted to supply the service will be expected to employ an accredited
optometrist and have the following equipment available:

Access to the Internet

Fundus viewing lens (e.g. Volk)

Slit lamp

Tonometer

Distance test chart (Snellen/LogMar)

Near test type

Appropriate ophthalmic drugs for pupil dilation
Patient information
A cataract information leaflet will be available and will be handed to patients as
appropriate.
[Last reviewed June 2012]
LOCSU Cataract Business Case.
Copyright © LOC Central Support Unit. Aug 2009. All Rights Reserved. [Rev Nov 2013].
Page 10 of 15
Appendix 2
Performance Monitoring Data Schedule
Case Level data:

Patient / GP / CCG identifiers

Patient demographics

Appointment(s) date(s) and type(s) – referral refinement or follow up

Outcomes
Contract Performance Monitoring Data: For each optometrist, by month / quarter:

Referrals by source

No. of cataract referral refinement episodes

Outcomes
o No. of onward referrals for surgery
o No. of patients discharged

No. of post – op follow ups

Patient satisfaction / complaints / SUIs
Annual joint audit
LOCSU Cataract Business Case.
Copyright © LOC Central Support Unit. Aug 2009. All Rights Reserved. [Rev Nov 2013].
Page 11 of 15
Appendix 3
Quality in Optometry Core Standards
Many aspects of clinical governance in optometric practice are enshrined in legislation or
regulation as well as in the College of Optometrists' Code of Ethics and Guidance on
Professional Conduct and in other guidance documents.
Level 1 is GOS contract compliance. This level will be used by NHS England Area Teams for
the purposes of checking and monitoring contract compliance. Contractors will be asked
to complete and submit a Level 1 report from time to time, together with an action plan
for rectifying any non-compliant issues. Practices that flag as outliers on this and other
criteria, together with a small random selection of others, may receive compliance visits.
Level 2 is clinical governance specifically designed for optometry community services
(previously enhanced services).
There are 3 audits/checklists available. Record keeping is an online version of the
spreadsheets available in Level 1 Q13.5. Infection Control and Information Governance
summarise relevant elements of Level 1 and present them in a manner appropriate to
community services.
Practitioner and non-clinical staff checklists summarise the knowledge that a contractor
will require of employees and practitioners as a part of complying with the GOS contract
Community Services
QiO level 2 covers clinical governance with a particular emphasis on community services.
The funding for this level of clinical governance is included as part of our proposal.
LOCSU Cataract Business Case.
Copyright © LOC Central Support Unit. Aug 2009. All Rights Reserved. [Rev Nov 2013].
Page 12 of 15
Appendix 4
Community Optometry Providers – NHS [insert name of
CCG]
NHS [insert name of CCG] has [insert number of practices] optical practices currently
providing General Ophthalmic Services. [insert name of LOC] LOC has surveyed these
practices and has received Expressions of Interest from [insert number] re becoming
providers of this service. All of the practitioners involved would undergo the
accreditation programme as previously described.
LOCSU Cataract Business Case.
Copyright © LOC Central Support Unit. Aug 2009. All Rights Reserved. [Rev Nov 2013].
Page 13 of 15
Appendix 5
Management of Community Services
[Insert name of LOC] LOC are now able to provide a full administration service for the
management of community services in conjunction with the Local Optical Committee
Support Unit.
The fully managed service includes the following:

Single point of contact for communications and queries relating to the service.

Supply of case data (monthly)

Supply of Contract Performance monitoring information with a covering report
(quarterly)

Exception reports (to be agreed; monthly as necessary)

Coordination of any remedial actions necessary

Attendance at four Contract Management meetings per year with CCG

Report of Annual audit of service
The local community service providers will utilise a web based management solution that
can provide all of the administration and data collection within the CCG area. OptoServ
collects data, provides activity and outcomes reports and generates electronic referrals and
invoices.
Stockport CCG, Bucks CCG and Oxfordshire CCG are all currently using the software,
created by LOCSU and Webstar Health and savings within these CCGs have already been
demonstrated, releasing valuable time and resources within the CCG. Webstar Health also
provides bespoke IT management services to disciplines such as Pharmacy. The cost of the
IT is included in the overall management cost of £12 per patient.
Key benefits

Using the software as part of the community service provides a ‘one stop shop’ that
includes administration, data collection and performance reports.

It can assist with contract compliance and identify for the CCG any outliers and
patient outcomes

Quicker, easier administration processes

Eliminates manual data processing but can fit in with a practice’s modus operandi

Reduces cost and time for the CCG

Manages the patient journey

Robust Audit available
LOCSU Cataract Business Case.
Copyright © LOC Central Support Unit. Aug 2009. All Rights Reserved. [Rev Nov 2013].
Page 14 of 15
Appendix 6
National Key Drivers
The national key drivers include:

Equity and Excellence: liberating the NHS (2010)

Right Care: Increasing Value – Improving Quality (June 2010)

NHS 2010-15; from good to great

Operating framework for the NHS in England 2010/11

Quality Innovation Productivity & Prevention (QIPP) agenda

HM Treasury (2010) The Spending Review Framework

Creating a patient-led NHS: Delivering the NHS Improvement Plan (March 2005)

Commissioning Framework for 2007-8

Implement care closer to home; convenient quality care for patients (April 2007)

Commissioning Framework for health and well-being (March 2007)

Trust, Assurance and Safety – the Regulation of Health Professionals (February
2007)

Safeguarding patients ( February 2007)

The UK Vision Strategy
LOCSU Cataract Business Case.
Copyright © LOC Central Support Unit. Aug 2009. All Rights Reserved. [Rev Nov 2013].
Page 15 of 15
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