Glaucoma Specification

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.
SCHEDULE 2 – THE SERVICES
A.
Service Specifications
Mandatory headings 1 – 4: mandatory but detail for local determination and agreement
Optional headings 5-7: optional to use, detail for local determination and agreement.
All subheadings for local determination and agreement
Service Specification
No.
Service
Intraocular Pressure Referral Refinement and OHT &
suspect COAG monitoring Service
Commissioner Lead
North Derbyshire CCG
Provider Lead
Period
3 Years
Date of Review
Annually
1.
Population Needs
1. National or local context/evidence base
The NHS North Derbyshire Clinical Commissioning Group (NDCCG) comprises 36
member practices with a registered population of 288,000 and covers five geographical
localities: Chesterfield, Dronfield, High Peak, North East and North Dales.
The NHS Hardwick Clinical Commissioning Group (HCCG) covers a population of
102,200 patients registered with 16 practices plus unregistered patients within the
geographical boundary of the CCG. NHS Hardwick CCG practices are based within
Bolsover, North East Derbyshire and the border with Amber Valley
The current provision of ophthalmic services in North Derbyshire and Hardwick is inequitable
with no community based provision of OHT and suspect COAG monitoring. All takes place in
the acute trust.
The number of patients who are referred for suspect Open Angle Glaucoma and then found
to have no Glaucoma is around 40%. These false positive referrals cause unnecessary
anxiety to the patient and are a waste of hospital resources.
NICE Guidance
NICE Clinical Guideline 85 (Diagnosis and management of Chronic Open Angle Glaucoma
and ocular hypertension) issued 22 April 2009 (http://www.nice.org.uk/CG85) sets out how
best to diagnose COAG and OHT, how people with COAG, OHT or at risk of COAG should
be monitored, and which treatments should be considered.
Affecting an estimated 480,00 people in England, COAG is a common condition involving
optic nerve damage and loss of the visual field that can lead to blindness if it’s not diagnosed
early and treated promptly. Around 14% of UK blindness registrations are due to glaucoma.
However many people won’t know that their eyesight is at risk – there are usually no
symptoms until the later stages when their vision is already seriously damaged. OHT (raised
1
pressure in the eye) is a major risk factor for developing COAG, although COAG can occur
with or without raised eye pressure. Glaucoma is more common with increasing age, and
people of African descent or with a family history of glaucoma may be at greater risk of
developing the condition. With changes in population demographics the number of people
affected by the condition is expected to rise. Once diagnosed, people with COAG need
lifelong monitoring so that any progression of visual damage can be detected. Controlling
the condition to prevent or minimise further damage is crucial to maintaining a sighted
lifetime.
Implications of NICE guidance
Constraints of a GOS sight test, and changes to NICE guidelines resulted in optometrists
referring all cases of suspect glaucoma to secondary care for confirmation of the diagnosis
and treatment where necessary. This works well when the diagnosis is positive. However,
there is no simple single test for glaucoma and this, coupled with the low prevalence of the
condition, makes it difficult to detect with certainty. Referral refinement by repeating visual
fields and intra-ocular pressures on another occasion has been shown to reduce onward
referrals by as much as 40%.
Previously the threshold for OHT was set by local ophthalmologists and in most cases was
around 25 mmHg. This lowering of the threshold (to 21mmHg) has increased the number of
referrals by community optometrists who are now following the NICE guideline. However,
most optometrists measure the pressure using an air-puff tonometer. These are considered
by NICE to be less accurate, and so repeating the pressures using Goldmann tonometry will
reduce the number of false positive referrals. The use of Goldmann tonometry is not a
requirement of a GOS sight test, although it is a core competency of optometrists.
2.
Outcomes
2.1
NHS Outcomes Framework Domains & Indicators
Domain 1
Domain 2
Domain 3
Domain 4
Domain 5
2.2
Preventing people from dying prematurely
Enhancing quality of life for people with long-term
conditions
Helping people to recover from episodes of ill-health or
following injury
Ensuring people have a positive experience of care
Treating and caring for people in safe environment and
protecting them from avoidable harm
Local defined outcomes
See 4.3 for detailed outcomes
2
3.
Scope
3.1
Aims and objectives of service
Service Outline
Level 1 - The service will be available to patients who are suspected of having glaucoma at
their GOS or private eye test where one or more of the following applies:
a.
The IOP in either eye exceeds the following levels taking into account NICE
and College of Optometrist guidance:
b.
65 years and below
21mmHg
Above 65 years and up to 80 years
25mmHg
Above 80 years of age
26mmHg
A visual field defect consistent with glaucoma is detected in either eye.
This is a diagnostic test service only, to help ensure the appropriateness of referrals to
hospital eye services. The service will be provided in the community by optometrists with the
appropriate skills, training and equipment.
Level 2 - Patients who have a confirmed diagnosis of OHT or suspect COAG and who are
stable at the Hospital Eye Service i.e. are at low risk of conversion to COAG. The hospital
eye service will determine the referral criteria of stable glaucoma patients from the acute trust
in to the community.
3.2
3.2.1
Service description/care pathway
Level 1 - Pathway





When a patient is seen in primary care and glaucoma is suspected, a referral is
made to the Level IOPRR (IOP Referral Refinement) Provider.
Upon receipt of a glaucoma referral refinement form the IOPRR Provider will
contact the patient within 5 working days and offer a refinement appointment,
which should be within 2 weeks. The referring Optometrist should ensure
patients are aware that they should return to their referring Optometrist for future
GOS sight tests.
Where the patient has refused a referral, the provider shall record this on the
patient’s record.
The provider shall provide the patient with a paper copy of their referral form, if
requested and ensure mechanisms are available to ensure outcomes are shared
with the referrer.
The IOPRR Provider should check the findings. This means if the patients IOP is
greater than the threshold levels stated in 3.1a the IOPRR provider should:
•
•
•
Re-check the IOP using contact Goldman Style Applanation Tonometry
Probe (such as Goldmann and Perkins).
Examine and record the visual fields where appropriate.
Examine the optic disc for any other signs of glaucoma including optic disc
and anterior chamber angles and conditions associated with glaucoma.
*It would reduce the number of visits required of a patient if they were seen during
the same appointment, however 1. Repeat visual field testing should be done on a
separate day 2. If IOPs have been taken with GAT as part of the routine eye
examination, the IOPs should be checked on a separate day, however if as part of
3
the routine eye examination the IOPs have been checked with a NCT, it would be
reasonable to check them with GAT. Patients should be reviewed at least one week
later and within 4 weeks.
There are three possible outcomes from repeating this test:
1. Outcome Negative
The results are within normal limits and the patient can be discharged. At risk groups should
be monitored at appropriate intervals under GOS.
2. Outcome positive
The pressure is confirmed as 22–32 mmHg and the patient is referred to the OHT diagnosis
pathway (Hospital Eye Service) as indicated by their age and NICE Guidelines.
Pressure > 32 mmHg is confirmed and the patient is referred to consultant ophthalmologist
for urgent assessment
The IOPRR provider will be expected to communicate his findings and actions to the referring
optometrist.
If the patient is subsequently referred on to a secondary care provider it is important to put all
the clinical findings, patients’ demographics and GP details on the GOS18, ensure the patient
understands they have a choice of secondary care provider, ensure it is legible, then send the
form using the current GOS18 pathway.
3.2.2
Level 2 – OHT/Suspect Glaucoma Monitoring Pathway
This is completely separate to the Level 1 Pathway and providers may offer either
Level 1 or 2 or both
The procedures and skills required for Level 2 are also core competency. However, it is
expected that accreditation in the form of a validation of knowledge and skills takes place.
With the completion of WOPEC Level 1 & 2 no further accreditation is required.
The accredited optometrist will carry out and interpret slit lamp mounted Goldmann
tonometry, suprathreshold perimetry, Van Herick’s test, dilated slit lamp biomicroscopic
examination of the optic nerve head and digital photography of the optic nerve head with the
means to measure the cup : disc ratio. Additionally, providers will have knowledge of the
Hospital Eye Service pathways.
All providers should be registered with General Optical Council for a minimum of 12 months
post qualification.
The Providers shall be responsible for ensuring all persons employed or engaged by the
Providers in respect of the provision of the services under the Contract are aware of the
administration requirements of the service.
•
•
•
•
•
When a patient with a confirmed diagnosis of OHT or suspect COAG and who is stable
shall be referred to the Level 2 provider.
Patients are monitored at regular intervals as specified by NICE.
Patients will be referred to this pathway from secondary care with an individual
management plan, and local care protocols will be issued
The accredited optometrist will carry out slit lamp mounted Goldmann tonometry,
suprathreshold perimetry, Van Herick’s test, dilated slit lamp biomicroscopic examination
of the optic nerve head and digital photography of the optic nerve head with the means to
measure the cup : disc ratio
There are two possible outcomes from these tests:
1. No change in clinical status. Next appointment as per the agreed interval.
2. Change in clinical status as per NICE Guidance. Patient is referred to Hospital Eye
Service
4
There may be occasion where a query remains around the results obtained, in which
case the provider may follow-up the patient at a later date, but by this stage these are
deemed to be in the minority.
3.3
Population covered
The community Intraocular Pressure Referral Refinement and OHT and suspect
COAG monitoring service will be applied to patients registered to a North
Derbyshire/Hardwick CCG GP.
3.4




Any acceptance and exclusion criteria and thresholds
The Provider/s have a responsibility to ensure the patient is registered to a relevant
GP.
Patients assessed as having a raised intra-ocular pressure as per section 3.1 Service
Outline
Aged 18 years or older
Patients registered with a North Derbyshire/Hardwick CCG GP
Exceptions





3.5

Acute glaucoma (angle-closure or rubeotic) is a referral emergency and should be
referred via the accepted urgent referral route
Referral pressures over 32mmHg detected at first optometrist visit will not be sent for
a refining appointment, but a direct referral to Secondary care will be made.
Patients under 18 years of age
Patients not registered with a North Derbyshire / Hardwick CCG GP
Any patient who meets the criteria for referral under the 2 week urgent referral
pathway
Criteria for delivery of service
Providers will be required to demonstrate that performers are clinically competent to
deliver this service, and have undertaken the WOPEC distance learning package for
glaucoma, plus attendance on a practical Goldmann training session (for delivery of
level 2 service) and attend refresher sessions as required.

Providers will be required to demonstrate that premise and equipment are
appropriate for the delivery of this service. In signing this contract, Providers are
confirming this is the case. If necessary inspections can be undertaken via the Area
Team programme of Optometry practice visits.

Providers will be required to demonstrate that they have robust recording procedures
and will be required to submit quarterly returns to the CCG.

For referrals, providers will offer ‘choice’ of local hospital to the service user. If a
service user requests an appointment at a hospital outside of the local area (i.e. not
their local hospital), the referral will be sent to the GP for onward referral via the
choose and book system.

Providers will inform service users’ GPs of referral to hospital.

Providers will be required to produce a register of all service users referred to
hospital from a practice under this scheme.

Providers will be required to work proactively with service users and facilitate cooperative management of their care.

Providers will be required to demonstrate a robust call and recall system in respect of
Level 2 patients discharged by the Hospital Eye Service to the care of the IOPRR
provider. Evidence of internal audit of systems will be required.
5

3.6
Providers will ensure that they have all necessary continuing training and that they
have all necessary clinical networks set up as required.
Referrals
Referrals could come from:



An Optometric Practice following a routine GOS Sight Test
Hospitals – when a service user has been referred from an eye doctor, the current
rules apply, but the service user will be referred if required using the glaucoma
referral refinement pathway.
Any IOP referrals going directly to hospital are likely to be re-directed to an
accredited Optometrist by the Hospital, with the exception of urgent referrals.
3.7
Interdependence with other services/providers
Providers will liaise with other community optometrists, patients’ GPs, community
eye service provider/s and hospital eye services as required to ensure the effective
and efficient delivery of the IOP pathway.
3.8
Equipment Required
Standard eye sight (GOS) tests will have been conducted by a community
optometrist prior to referral to a provider using equipment already in practice.
The provider is expected to carry out a second diagnostic test of the eye using
disposable contact Goldmann Probe Applanation tonometry.
The Goldmann Probe is a “must have” piece of equipment in order to deliver this
service but can be mounted on the providers in-house equipment i.e. Perkins .
For any domiciliary patients who are unable to attend the practice for Goldmann
probe diagnosis the community optometrist’s current method of pressure testing will
apply.
•
•
•
•
3.9
Goldman Probe Applanation Tonometry
Slit lamp
Telephone
Camera for measuring cup:disc ratio
Additional Services
The CCG may seek to introduce other services in the future to meet any population,
service needs and to respond to any national/local drivers for change. As a
provider of this service, you may bid for such services as and when they are
commissioned.
3.10
Monitoring

Providers should undertake internal audits once in each financial year on an annual
cycle.

Providers may be required to produce further reports to the CCG upon request, which
may form part of Post Payment Verification audits.
6

Monthly reports (via minimum dataset) to be submitted to the CCG, with a more
detailed report quarterly providing the activity/outcome for each patient who has
completed the pathway. In addition to the reporting requirements indicated in the
Quality targets, the following information will be provided:
Level 1
Total number of patients seen for 1st tonometry
Total number of patients seen for 2nd tonometry
Number and % second readings within 7-14 days of first tonometry
Number and % of patients seen discharged as false positives
Number and % of patients referred into Secondary Care
Level 2
Total number of patients referred from Secondary Care for with management plan for
monitoring within Primary Care
Total number of patients referred back to Hospital Eye Service
Exception reports as to number of patients where a query remains around the results
obtained, which has required follow-up.
Indicative activity:
Level 1:
Indicative activity would suggest the following based upon the geographical coverage:
Goldmann tonometry assessments 839, Visual fields 240 totaling 1079
Repeat Goldmann 336
Full assessments (non-participating providers) 270
Level 2:
Patients requiring ongoing monitoring under Level 2 are likely to transfer from Secondary
Care over a 12 month period into Primary Care from the commencement of service. Patient
choice will still apply. Mechanism for transfer to be decided and advised prior to
commencement of service.
3.11
Payment
Level 1:
IOP - Goldmann Tonometry Assessment:
£20.00
Visual Field Assessment: Standard Automated Perimetry:
£30.00
It is envisaged that a maximum claim would be limited to 2 IOP repeats and 1VF
repeat per patient as appropriate.
Level 2:
Provision of the following:
£50.00
• Slit lamp mounted Goldmann tonometry
• Suprathreshold perimetry
• Van Herick’s test
• Dilated slit lamp biomicroscopic examination of the optic nerve head
• Digital photography of the optic nerve head with the means to measure the cup :
disc ratio
7
•
Onward referral and management of recalls as appropriate
As per section 3.2.2 a fee of £25 may be claimed if uncertainty remains, but these
are deemed to be unlikely.
3.12
Claims
Detail as to claims processes will be included in the contract under the Payment
Schedule.
4.1
Applicable national standards (e.g. NICE
4.1.1
NICE clinical guideline 85: Diagnosis and Management of Chronic Open Angle
Glaucoma and Ocular Hypertension
4.1.2
Joint Commissioning Guidance on Glaucoma by The Royal College of
Ophthalmologists and College of Optometrists (February 2013)
4.1.3
NHS Outcomes Framework 2013/14
4.1.4
Providers are to ensure the service is listed on Choose & Book (direct bookable
appointments is not necessary at this time but it may be a requirement in the future).
4.2
Applicable standards set out in Guidance and/or issued by a competent body
(e.g. Royal Colleges)
•
•
NICE Clinical Guideline 85, Diagnosis and management of chronic open angle
glaucoma and ocular hypertension.
Guidance on the referral of Glaucoma suspects by community optometrists. College
of Optometrists and The Royal College of Ophthalmologists – December 2009.
NICE Quality Standards: Glaucoma
Guidance on the referral of Glaucoma suspected by community optometrists. College
of Optometrists and The Royal College of Ophthalmologists – December 2009.
Equity & 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)
•
•
•
4.3
4.3.1
Applicable local standards
Accreditation
Level 1
The procedures and skills required for Level 1 are a core competency. It is expected
8
that all providers will maintain their core competency of Goldman probe Applanation
Tonometry. A refresher training package may need to be arranged if the performer
deems it a requirement. The package must cover practical skills assessment in slit
lamp Goldmann probe Applanation Tonometry.
Level 2
The procedures and skills required for Level 2 are also core competency. However, it
is expected that accreditation in the form of a validation of knowledge and skills takes
place.
The accredited optometrist will carry out and interpret slit lamp mounted Goldmann
Tonometry, suprathreshold perimetry, Van Herick’s test, dilated slit lamp
biomicroscopic examination of the optic nerve head and digital photography of the
optic nerve head with the means to measure the cup : disc ratio. Additionally,
providers will have knowledge of the Hospital Eye Service pathways.
All providers should be registered with General Optical Council for 12 months or
more. Registered practitioners should hold a relevant and current registration,
possessing the competence and skills as public health practitioners and be listed.
This needs to be evidenced.
The Providers shall be responsible for ensuring all persons employed or engaged by
the Providers in respect of the provision of the services under the Contract are aware
of the administration requirements of the service.
4.3.2
•
•
•
•
•
5.
Self Care and Patient and Carer Information
Patients should receive timely information regarding their assessment appointment
including:
When and where their appointment is
How to get to there
Any prior information relating to the assessment
Patients will receive written information on their condition and the reason for onward
referral (if applicable)
Patients should be made aware that for future GOS sight tests they should return to
their usual Optometrist.
Applicable quality requirements and CQUIN goals
Not applicable
6.
Location of Provider Premises
The Provider’s Premises are located at:
7.
Quality
Performance
Indicator
Individual Service User Placement
Threshold
Method of
measurement
Consequence of
breach
Report Due
Total number of patients seen
for 1st tonometry
Provider
information
returns
Service review
Monthly,
which
will also generate
payment
Level 1
Access
Total number of patients seen
for 2nd tonometry
9
Number and % second
readings within 7-14 days of
first tonometry (threshold
90%)
Number and % of patients
seen discharged as false
positives (40% discharge rate)
Number and % of patients
referred into Secondary Care
Level 2
Access
Total number of patients
referred from Secondary Care
with management plan for
monitoring within Primary
Care
Provider
information
returns
Service review
Monthly,
which
will also generate
payment
Evidence
provided of
relevant
qualifications and
CPD.
Service
suspended
pending remedial
action
Annual
Service review
Yearly update
Total number of patients
referred back to Hospital Eye
Service
Exception reports as to
number of patients where a
query remains around the
results obtained, which has
required follow-up (see 3.2.2)
Level 1 & 2 Requirements
Patient Safety
All providers have appropriate
qualification and equipment,
safe environment and
effective administration
systems
Evidence from
appropriate
commissioning
organisation as to
annual visits and
patient safety
incidents
Service User
Experience
Yearly survey of patients for
all relevant patients (currently
the Friends & Family Test is
not a requirement for
Optometry Contracts, but
providers may still wish to
pose the question).
Results of annual
Patient
satisfaction
survey
10
11

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