Download schedule 2 – the services

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
Commissioner Lead
Optometrist assessment and referral of patients with cataract
(DCRS)
Associate Director Commissioned Services
Provider Lead
Optometrist Practice Service Lead
Period
1st April 2014 – 31st March 2015
Date of Review
31st March 2015
1.
Population Needs
1.1
National/local context and evidence base
A cataract is an opacification (clouding) of the eye’s natural lens. It usually develops over a period of
time causing a gradual deterioration in eyesight and may eventually lead to blindness (NICE 2007).
The most effective treatment is surgical removal of a cloudy lens using an extra-capsular or intra
capsular technique. In both cases the affected lens is removed and replaced with a plastic lens (an
intraocular lens implant) which stays in the eye permanently. Cataract operations are performed
using a local anaesthetic and service users allowed home the same day.
Wigan Borough CCG is working to improve ophthalmology services across primary and secondary
care. This is in order to respond to an ever increasing demand for secondary care eye services; a
demand which is predicted to rise as a result of earlier diagnosis of chronic conditions, new
treatments and population changes. Eye care services have traditionally been a hospital based
specialty, however many ophthalmic assessments and treatments currently being carried out in
secondary care can be undertaken effectively in primary care.
This DCRS service delivered via Local Optometrists will support improving patient access to Cataract
surgery. Instead of patients being required to be referred from GPs directly to hospital for assessment
patients can instead be assessed by a locally accredited Optometrist.
2.
Outcomes
2.1
NHS Outcomes Framework Domains & Indicators
2.2
Domain 1
Preventing people from dying prematurely
Domain 2
Enhancing quality of life for people with long-term
conditions
Domain 3
Helping people to recover from episodes of ill-health or
following injury
Domain 4
Ensuring people have a positive experience of care
x
Domain 5
Treating and caring for people in safe environment and
protecting them from avoidable harm
x
x
Local defined outcomes

Reduce the number of Ophthalmology assessments which take place within secondary care

Reduce the incidence of preventable blindness due to Cataract in line with the Vision 2020
strategy
3.
Scope
3.1
Aims and objectives of service
The aim of the service is to improve access to the initial assessment and overall health outcomes for
patients with Cataracts. To deliver this aim the service will:
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3.2
Provide a high quality and efficient service to patients who present with a cataract at multiple
local Optometrist providers.
Reduce the total number of steps that most patients need to go through and the overall total
waiting time to surgery
Reduce the number of patients that are referred with a cataract but do not proceed with
surgery
Ensure patients are assessed by accredited Optometrists in a community setting working to a
best practice locally agreed pathway
Service description/care pathway
Pathway overview
 All patients with a suspected cataract should be referred to an accredited optometrist who will
undertake an extended assessment and provide counselling on the risks and benefits
associated with cataract surgery

Patients requiring a cataract assessment following an initial sight test with a non-accredited
optometrist should be referred directly to an accredited optometrist using the GOS 18 referral
form. GOS 18 cataract referrals to WBCCG GPs from out of area optometrists may be
redirected to an accredited optometrist

Patients should complete a self-assessment questionnaire prior to their appointment with an
accredited optometrist for the extended assessment – copies of this will be made available to
all optometrists

The main purpose of the extended assessment is to elicit relevant ocular, medical and social
information to ensure patients receive the most appropriate treatment and care

Communicating the relative risks and benefits of cataract extraction should help identify, at an
early stage, patients that do not wish to proceed with surgery.

Clinical guidelines and a patient self-assessment questionnaire will support the accredited
optometrist in differentiating between:
(i)
(ii)
Cataract patients that are not currently appropriate for referral for NHS treatment
(either where the patient does not want be considered for cataract surgery or the
patient has chosen to be referred privately)
Cataract patients that are suitable for direct referral to the hospital
Care Pathway Protocol
Timescales for service provision
 The Accredited Optometrist will be expected, within reason, to provide appointments within 3
working days, subject to usual opening hours. This would be expected whether the patient is
referred from the GP or another source.

The interval between the original sight test and the DCRS assessment should be no longer
than one week as the scheme is intended to provide a speedy referral pathway having
omitted the need for referral via a GP.

GP’s / patients will be encouraged to phone practices prior to arrival to ensure the selected
DCRS Optometrist is available. Patients being referred from GP’s will have an up to date list
of Accredited DCRS Optometrists, including contact details
Patient eligibility
 It will be the optometrist’s responsibility to establish the patient’s eligibility. They should only
assess and refer patients under this scheme who have an Wigan Borough Clinical
Commissioning Group General Practice. No payment will be made for other patients.

Patients who do not have a WBCCG GP should be referred to their GP using the GOS 18
form.

Patients who are found to have a co existent ocular condition undiagnosed or untreated by
the hospital should be referred under GOS.

Details of GPs and Practices can be accessed via the Wigan Borough CCG website
(www.wiganboroughccg.nhs.uk) or alternatively by accessing the NHS Choices website
directly at www.nhs.uk A hard copy GP list is also available.

Should you have any difficulties in determining whether or not a patient’s GP is registered
with the CCG you can also contact WBCCG on 01942 482966.
The patient self-assessment questionnaire
All patients are required to complete a self-assessment questionnaire detailing past eye history,
general medical history, medication, mobility and social support.
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The questionnaire should be given to the patient and completed prior to their appointment
with the accredited optometrist
The self-assessment questionnaire should be checked by the accredited optometrist and
areas of uncertainty should be clarified by the optometrist prior to any decision to refer
The self-assessment questionnaire should be used to identify the care that is most

appropriate to the needs of the patient
When a hospital referral is required, the self-assessment questionnaire should be attached to
the referral /reporting form (a copy may be kept by the optometrist for their records)
The cataract assessment
An extended cataract assessment should be used to assess the ocular health of the patient, provide
counselling on surgery and identify any relevant medical and social information
This extended assessment will consist of:
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Dilated fundoscopy
Intraocular pressure measurement
Slit lamp examination
Discussion of the completed patient Health Questionnaire
Counselling the patient regarding the risks and benefits of cataract surgery (see 2.3 below)
Making the patient aware of the concept of CHOICE of provider
Completion and submission of all reports and documentation in accordance with the scheme
protocol.
Further information is included in the pre-operative assessment section of the College of Optometrist
(2003) “Framework for the Optometric Co-Management of Patients with Cataract”.
The final decision on whether referral is indicated should be at least one week after the initial visit
preferably with the patient and their relative or carer present. This allows a period of reflection and
consideration for the patient.
Risks and benefits
The patients should be counselled on the risks and benefits associated with cataract surgery

In many patients the cataract operation should improve their eyesight, however the final
visual result may not be as good as for someone who has had no eye problems
 As with any form of surgery, there are also some risks and complications
 Minor complications may include bruising around the eyelids, redness and irritation in the eye
 Rarely the delicate lining of the lens capsule is damaged during the operation – if this occurs
an additional procedure may be required. This can affect the vision afterwards
 Major complications are rare (occurring in under one in each 1000 operations).These include:
o Haemorrhage inside the eye
o Infection inside the eye following the operation
o Retinal detachment or disturbance
o Reduced or loss of vision
o Corneal clouding
o Second procedure
o Loss or disturbance of vitreous/lens
o Blindness
o
It is possible that the patient may lose all sight in the eye if they get one of these rare complications
For more information on the risks/benefits of surgery, including complication rates, please refer to the
Counselling considerations in cataract surgery article by Moriarty, and the College of Optometrist’s
“Framework for the Optometric Co-Management of Patients with Cataract”. Copies of both of these
are available
Information for patients
Patients that are considering referral for NHS treatment should be:
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Given a copy of the RNIB/Royal College of Ophthalmologists leaflet “Understanding
cataracts”
Advised of the referral process & the process by which hospital appointments will be made.
Given a copy of the Choice Centre leaflet (if an NHS referral is being made) patient should be
advised to contact the Referral Information centre “Choice centre” after 48 working hours
Assessment following a sight test elsewhere
You may have a patient referred to you following a sight test by an optometrist who does not
participate in the scheme. This may be a colleague within your practice or an optometrist from
another practice. In these cases the optometrist may refer the patient direct to you or provide the
patient with a list of accredited optometrists to choose from.
If the patient was assessed by an optometrist outside of the WBCCG area, the referral may come via
the patient’s GP. Likewise, the GP may refer the patient direct to you or provide the patient with a list
of accredited optometrists to choose from. In each of these cases a copy of the GOS18 should be
supplied and you should assess and counsel the patient in the same way, claiming the same fee.
If you have reason to be unhappy about proceeding on the basis of the previous sight test, then you
may test the patient again, claiming another GOS sight test fee (assuming the patient is eligible for
GOS). You should use code 5.3 or 6 to justify the early test.
Domiciliary Visits
Domiciliary visits may be provided for patients that are genuinely housebound and are unable to
attend the optometrist’s practice for the cataract assessment. The initial sight test and visit will
generally be covered by GOS. Where a second visit is required to complete the cataract assessment,
a second domiciliary visiting fee will paid to the accredited optometrist in addition to the assessment
fee. Please note only one domiciliary fee will be paid per patient assessed.
The criteria for domiciliary visit eligibility are consistent with GOS sight tests.
In summary:
 All possibilities for enabling the patient to attend the practice should be suggested and the
patient must be asked what illness or disability prevents them from attending the practice
 The optometrist will need to check that the patient, or in the case of a residential home, the
manager, is aware of that a domiciliary visit is only available if the patient is unable to leave
home
 Practitioners are not expected to exercise any clinical judgment in deciding whether the
condition is as disabling as the patient alleges.
At the discretion of the accredited optometrist, domiciliary patients that are referred via a practitioner
that has completed the initial sight test but does not participate in the cataract scheme may be treated
differently. For these patients a domiciliary visit for the cataract assessment is not required:
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Send the self-assessment questionnaire to the patient or, if in a residential home, the
manager
This should be returned to the optometrist with a copy of the patient’s repeat prescription list
Ask the patient/residential home manager to confirm that the patient is still interested in
surgery
Complete the referral/reporting form, clearly indicating in the additional information section
that no assessment was provided
The assessment fee (though not the domiciliary fee) will still be payable providing the referral /
reporting form is complete and the self-assessment questionnaire attached.
Practitioners should note that they are responsible for decisions made regarding the need for
assessment and referral, not their employer.
Patients that fail to confirm or attend their appointment
The accredited optometrist will be responsible for following up patients that fail to confirm their
appointment or where notified of patients that fail to attend a booked appointment at the hospital:
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Receipt of referral by Choice Centre – If in the opinion of the referring Optometrist a patient
would have difficulties in contacting Choice Centre it is recommended that the referral be
noted accordingly. In such cases Choice Centre will endeavor to contact the patient in the
first instance by phone at the number quoted on the referral form or failing this by letter.
Should the patient choose not to proceed with the referral Choice Centre will inform the referring
optometrist
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Initial outpatient appointment, pre-operative assessment or day of surgery – if the patient fails
to attend their initial outpatient appointment/ the pre-operative assessment appointment or
their day of surgery they will be classified by the hospital as a DNA (did not attend). Patients
that DNA may be automatically discharged, though the consultant has the right to override
this if he/she believes there are medical reasons why the patient should not be immediately
discharged. If the patient is discharged following a DNA, a letter should be issued to the
referrer advising them of this.
In either of these cases it is the optometrist’s responsibility to contact the patient and identify whether
he/she is still interested in surgery.
3.3
Population covered
Any patient registered with a Wigan Borough Clinical Commissioning Group GP
3.4
Any acceptance and exclusion criteria and thresholds
Patients suitable for direct referral to hospital
Patients are suitable for direct referral if:
Visual impairment
Visual impairment is principally due to cataract, and at least one of:
 Reduced visual acuities in affected eye(s)
 Glare or other visual disturbances
 Experiencing difficulty with normal day to day activities
General suitability
 Willing to undergo cataract surgery
 Good social support, including transport to and from hospital and support to put in eye drops
(if unable to do so themselves)
Patients not requiring referral for NHS treatment
Some cataract patients will not require a referral to the hospital for NHS treatment. These will be:
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Patients that, having been counselled on the risks and benefits of cataract extraction, choose
not to proceed with surgery
Patients who were found on assessment to have ocular co-morbidity that makes them
unsuitable for this scheme
Patients that choose to be referred for private treatment
Patients that have been assessed under the service but have chosen to be referred for private
treatment rather than NHS surgery should be referred directly to a named consultant.
3.5
Interdependence with other services/providers
Providers will be expected to liaise with other Optometrists and General Practices in the inter referral
and management of patients.
3.7 Referral Pathway
NB the Optomanager system automatically e-faxes your referral & questionnaire to the RBMS and
the GP therefore you are not required to manually fax. It also automatically submits your claim
therefore this action is not required
The unit price(s) and total amount claimed
£49.00
per patient assessed
£34.70
per domiciliary visit undertaken
4.
Applicable Service Standards
4.1
Applicable national standards (eg NICE)
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4.2
NICE Guidelines Implantation of accommodating intraocular lenses for cataract (IPG209)
Applicable standards set out in Guidance and/or issued by a competent body (eg
Royal Colleges)
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4.3
The Royal College of Ophthalmologists: Cataract Surgery Guidelines September 2010
Applicable local standards

None
5.
Applicable quality requirements and CQUIN goals
5.1
Applicable Quality Requirements (See Schedule 4 Parts [A-D])
The Service Provider will:

Demonstrate compliance with all current regulatory requirements and relevant national
standards including the National Institute of Clinical Excellence (NICE) Quality Standards; in
line with Clinical Governance requirements.
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Ensure that all Provider Staff are suitably qualified and competent. Internal arrangements
must be in place for maintaining and updating relevant skills and knowledge base; that also
incorporates and supports the arrangements for staff supervision.
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Ensure that lines of professional and clinical responsibility and accountability are clearly
identified.
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Ensure that all premises and equipment used for the provision of the enhanced service are at
all times suitable for the delivery of those services and sufficient to meet the reasonable
needs of patients or clients.
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Providers must follow infection control policies and procedures that are compliant with
national and local guidelines. All infection control and decontamination measures must meet
the standards within the Health and Social Care Act (2008) “Code of Practice for Health and
Social Care on the Prevention and Control of Infections and related guidance”.
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Providers must ensure that there is a robust system in place for the reporting of incidents
(including serious incidents) and near miss events. All incidents must be documented,
investigated and followed up with the required corrective action/s. Any lessons learnt from
incidents should be shared internally and across the localities to enhance wider learning from
incidents, and with the service commissioners.
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Providers must ensure that there is an effective complaints procedure for place that can
demonstrate compliance with the current regulatory requirements for the management of
complaints in relation to the provision of the enhanced service. Evidence of compliance must
be available for audit purposes.
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Ensure that treatment, care and information provided is culturally appropriate and is available
in a form that is accessible to people who have additional needs, such as people with
physical, cognitive or sensory disabilities, and people who do not speak or read English.

All providers are required to adhere to quality NHS guidelines on confidentiality and consent.
For further information please refer to the quality requirements as detailed within schedule 4 parts A –
D.
5.2
Applicable CQUIN goals (See Schedule 4 Part [E])
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6.
None applicable
Location of Provider Premises
The Provider’s Premises are located at the approved optometrist practice(s)
7.
Individual Service User Placement
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Not applicable