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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