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The Royal College of Ophthalmologists INVITED SERVICE REVIEW FOR THE OPHTHALMOLOGY SERVICE AT THE SHREWSBURY AND TELFORD HOSPITAL NHS TRUST Date of Review: 7th and 8th September 2015 Contents 1. Review Team .................................................................................................................. 2 2. Background to the request for review ............................................................................. 2 3. TERMS OF REFERENCE FOR REVIEW OF OPHTHALMOLOGY SERVICE ....... 3 4. General Terms of Reference from the RCOphth ............................................................ 4 5. Serious Incidents ............................................................................................................. 6 6. Reviewer Findings ........................................................................................................ 13 7. Ophthalmology Services at SATH................................................................................ 14 8. Management and Governance...................................................................................... 20 9. Workforce Planning ..................................................................................................... 20 10. Estate and Facilities ................................................................................................... 21 11. Summary .................................................................................................................... 22 12. Recommendations ...................................................................................................... 26 Ref: IRR00003 1 1. Review Team Mr Richard Smith, Consultant Ophthalmologist, Buckinghamshire Health Care NHS Trust and former Chair of Professional Standards Committee, Royal College of Ophthalmologists Professor Bernard Chang, Consultant Ophthalmologist and Lead Clinician in Ophthalmology at Leeds Teaching Hospitals NHS Trust and Chair of Professional Standards Committee, Royal College of Ophthalmologists. 2. Background to the request for review This review was requested by Shropshire Clinical Commissioning Group (SCCG) and was undertaken with the full cooperation of Shrewsbury and Telford Hospital NHS Trust (SATH). The request for the review followed the declaration of a number of serious incidents relating to the ophthalmology service at SATH, some of which, following investigation were reported to have resulted in actual harm to patients. Ref: IRR00003 2 THE ROYAL COLLEGE OF OPHTHALMOLOGISTS 3. TERMS OF REFERENCE FOR REVIEW OF OPHTHALMOLOGY SERVICE The Shrewsbury and Telford Hospital NHS Trust To provide both the Clinical Commissioning Group and Trust with an external view of the working practices and standards within the ophthalmology department and make recommendations for the consideration of the Chief Executive and Medical Director of the Trust. This will follow the process set out in “RCOphth Guide to Invited Reviews” version March 2013 and include: 1. Quality Outcomes including: a. A clinical review of the Serious Incidents reported by the Trust of individuals who have suffered Moderate or Severe preventable harm whilst under the care of SaTH NHS Trust Ophthalmology service. There have been 17 patients reported by the Trust via the Serious Incident process who have had either a delayed diagnosis or delayed outpatient appointment (both classifications have been used by the Trust). b. A clinical review of seven ophthalmology patient case-notes included in the cohort were identified by the Trust as “lost to the booking system” who have waited beyond 52 weeks for first outpatients. c. Concerns raised by patients and the public relating to Ophthalmology services some of which relate to appointments delays or delays in receiving treatment. 2. Service design/Caseload This will include: a. Assessment of compliance with national guidance and standards for care and treatment where available b. Information sharing and links with primary care, acute and community services c. Staffing and workforce arrangements d. Child protection arrangements (if applicable) e. Clinical governance including accountabilities and quality improvement f. Benchmarking of services with equivalents elsewhere where possible and highlighting good practice Ref: IRR00003 3 4. General Terms of Reference from the RCOphth To make recommendations for the consideration of the Chief Executive and Medical Director of the Trust and the CCG as to: Whether there is a basis for concern about the service in light of the findings of the review. Possible courses of action which may be taken to address any specific areas of concern which have been identified. Provide an overall assessment of the pattern of work across the department and the workload given the numbers of ophthalmologists and subspecialties of the consultant ophthalmologists. Provide advice on best practice referral mechanisms between consultants to ensure maximum benefit from subspecialty expertise and provide comments on the way this is currently organized. Provide advice on best practice clinical governance frameworks specific to ophthalmology. Specifically how clinical governance issues might best be approached by the consultant staff in relation to the current standards required in ophthalmology and what College guidance should they be examining regularly and benchmarking themselves against. Some advice in relation to best practice from elsewhere would be useful in this regard. Provide advice on use of current best practice to reduce the follow up burden by moving work into the community or using nurse follow up. Implications for ophthalmology training in the department. List of Personnel Interviewed This report has been compiled from information gathered from a) Face to face interviews on the 7th and 8th September 2015 with: Mr Mark Cheetham, Scheduled Care Group Medical Director Mr Stuart Thompson, Clinical Director for Head and Neck and Ophthalmology Lisa Challinor, Centre Manager for Head & Neck and Ophthalmology Fiona Gabbitas, Matron for Head & Neck and Ophthalmology Debbie Kadum, Chief Operating Officer Sarah Bloomfield, Director of Nursing and Quality Dr Edwin Borman, Medical Director Brenda Maxton, Patient Safety Advisor Gareth Downes, Patient Access Booking Team Cath Tranter, Patient Access Booking Team Karen Maloney, Performance Administrator Marie-Claire Wigley, Senior Ophthalmic Nurse Jenny Bridges, Senior Ophthalmic Nurse Ref: IRR00003 4 Andrena Weston, Patient Access Manager Janine McDonnell, Centre Manager for Patient Access Mr Ewan Craig, Consultant Ophthalmologist Mr Paul Haigh, Consultant Ophthalmologist Mr Jagadish Sardar, Consultant Ophthalmologist Ms Lakshika Perera, Consultant Ophthalmologist Mr Tarek Hammam, Consultant Ophthalmologist Mr Prasad Rao, Consultant Ophthalmologist Mr Suresh Sagili, Consultant Ophthalmologist Mr Andrew Callear, Consultant Ophthalmologist (Mr Robert Dapling, Consultant Ophthalmologist was on leave and sent apologies) Ms Linda Izquierdo, Director of Nursing, Quality, Patient Safety and Experience, Shropshire CCG (by telephone) b) Details (provided by SATH) of the 17 serious incidents (SI) referred to in the Terms of Reference, (denoted RCA 1 – RCA 17 below), with person-identifiable information removed, but including details of investigations, Root Cause Analysis (RCA) and actions taken. The SI declarations and investigations took place during 2014 and 2015, though the sentinel events leading to the SI cover a wider time period. A comprehensive folder of background Information provided by SATH including information on back ground and future developments (Ophthalmologists deep dive paper), Team Structure, Service Overview, Previous Overview, Clinical Protocol, Standard Operational Procedures, Service Specification, Audit Data, Pathways, Complaints , Litigation, Patient Safety Reports, RCA, Consultant Job Plans, Minutes of Governance meetings, Minutes of Departmental meeting, Minutes of Consultant meetings and Consultant / Nursing timetables. Ref: IRR00003 5 5. Serious Incidents Seventeen serious incidents were investigated: Serious Incident Case 1. The patient had two intravitreal steroid injections for Retinal Vein Occlusion and was planned for review for one month following the second injection. However, the review did not take place; the patient was referred two years later by which time no further interventions to improve vision were possible. Case 2. This patient had a rare congenital anomaly of both eyes which was complicated by raised intraocular pressure. The patient also had a learning disability and attended with a carer. The patient was seen in the Glaucoma specialist clinic and attended in April 2012 with a plan for 6 month review. An appointment does not seem to have been made and the patient was referred again in August 2013 but the appointment was cancelled as the clinic had been reduced and the patient had been placed on a pending list. An appointment in May 2014 was missed. Four subsequent appointments were either cancelled by the patient or not attended and the patient finally attended in September 2014 by which time the vision had deteriorated irreversibly because of glaucoma. Case 3. This patient was undergoing treatment with Lucentis for “wet” AgeRelated Macular Degeneration (AMD) and required a laser capsulotomy Ref: IRR00003 Comment Although the follow up appointment should have been made following this treatment it is unclear if this patient suffered avoidable vision loss as a result. There had been little response to the first steroid injection and the prognosis for significant visual improvement with the second injection was poor. Action taken including improved information to the patient about follow up from intravitreal injections. The patient was appropriately informed and an apology offered. Although the patient initiated cancellations and missed appointments were a factor in the patient being lost to follow up for almost 2½ years, there was a 7 month delay in offering follow up appointments which should have occurred in October 2012. It is possible that this may have contributed to the deterioration of the patient’s vision. It is also relevant that this was a vulnerable patient with a learning disability; this patient had a complex form of glaucoma which would normally be managed in specialist glaucoma service. This patient also had two sets of medical records, parts of which were not filed in chronological order. The Trust has involved the Safeguarding Nurse in this patient’s care and is reviewing the glaucoma service. The fact that the patient required a laser capsulotomy which is not a routine part of the AMD pathway seems to have contributed to the patient being lost to 6 following the seventh Lucentis injection in July 2012. A laser capsulotomy was performed but the patient does not seem to have been returned to the macular clinic and was not seen again until August 2014 by which time the visual acuity had reduced from 6/60 to 2/60 and had become unlikely to benefit from further treatment of this eye. follow up from the AMD clinic. Although the delay in follow up may have contributed to the situation where the patient’s vision ceased to benefit from further treatment, the reduction in vision in this period was modest and it is possible that the patient’s vision would have deteriorated to this degree even with further treatment during this two year period. The Trust has since appointed a Coordinator for the AMD treatment service with a remit to ensure timely follow up appointments. Case 4. This patient was referred in It is very unusual for a flat choroidal February 2013 with raised intraocular naevus to develop into a melanoma and pressure and was found incidentally to where no suspicious features are present, have a small flat pigmented area in the most departments discharge patients retina of the right eye. A 12 month after providing them with a clinical review appointment was requested photograph with a recommendation for which should have occurred in February annual review by a community 2014 but in October 2014 a review of optometrist in line with National Ocular uncashed appointments found that this Oncology referral recommendations. It is patient had not received an appointment. impossible to determine at what point The patient was reviewed in November this patient’s naevus underwent 2014 and a choroidal melanoma was malignant transformation, but in our identified in the right eye. The patient view, it is unlikely that the 7 month delay was referred to a tertiary centre for in follow up has significantly altered the treatment as a result. prognosis for this patient. The Trust has improved the process for ensuring all patients are accounted for at the end of the clinics as a result. Case 5. This was an elderly patient who No information was given about the had a blind left eye and AMD in the right patient presenting level of vision or final eye, the patient was seen on several level of vision so it is not possible to occasions following a referral in June comment on what level of harm to vision 2013 with some delays to appointments occurred as a result. on a number of occasions, none of which Delays were attributed to lack of capacity were long delays taken individually. to the AMD service. Case 6. This patient was undergoing The precise reason for delay in follow up Lucentis injections for AMD and was is unclear, but there is little doubt that reviewed in January 2014 with the the delay in follow up contributed to the intention that further injections of deterioration in the patient’s vision. Lucentis should be given (within two weeks). The patient seemed to be Ref: IRR00003 7 unaware of the need for a further injection and was seen in June 2014, by which time the vision had reduced from 6/18 to 6/36. An injection was given three weeks later by which time the vision had dropped further to 3/60. Case 7. This patient from Wales was referred with raised intraocular pressure in her only seeing eye. The referral was graded as routine as there was no additional information at the time to suggest high risk characteristics. Appointment was offered 32 weeks later in line with the current referral to treatment guidance for patients from Wales, but the patient was unable to attend and cancelled the appointment on the day. The next available appointment was 12 weeks later at presentation the patient was found to have advanced glaucoma and is now severely visually impaired. Case 8. This patient had a history of hepatitis and intravenous drug use and self-referred to the Acute Referral Clinic with a history of red eye and reduced vision. The patient had initial triage assessment from a nurse who requested a review by a doctor in the eye department. The visit took place at lunch time and the nurse reported that the doctor did not feel it necessary to see the patient and requested that the patient should return to a week day clinic. When the patient attended two days later he was found to have Ref: IRR00003 The Trust has subsequently appointed a booking coordinator for macular Degeneration treatment. Although the total delay between the referral from the optometrist first assessment at the hospital almost certainly led to avoidable progression of glaucomatous damage, the information provided by the referrer did not identify any risk factors for rapid progression which would have prompted an urgent prioritisation, and the patient would have been seen within the time frame specified by the Commissioner had it not been for the patient initiated cancellation. Clearly it is desirable for patients with suspected Glaucoma to be seen within a significantly shorter time period but rapid progression of glaucomatous visual field loss within a few months is unusual without the presence of “red flag” findings (e.g. very high pressure, advanced visual field defects). The Trust has subsequently amended its booking processes to try to ensure that patients from England and Wales are prioritised equally. It is likely that the condition would have been identified earlier had the patient been reviewed by an ophthalmologist on the day he presented and treatment initiated at that time. This may have resulted in a more favourable visual outcome. The patient demonstrated several red flag “symptoms” or signs at presentation (red eye reduced vision history of intravenous drug use). The department has strengthened the protocol for nurse triage within the acute referral clinic to allow the nurse to 8 endophthalmitis requiring immediate admission for intravitreal injection of antibiotics. The patient subsequently developed a detached retina requiring further surgery. At final review the visual equity was 6/36. Further improvement maybe possible. Case 9. This patient had been receiving treatment with Lucentis for AMD since August 2012 and received his 10th injection on the 19th April 2014 with a planned review for 4 weeks. Visual acuity was 6/12 at this time. This patient was next reviewed on the 8th August 2014, after apparently being lost to follow up and was listed for urgent injection which was given on the 6th September 2014 at which time the visual acuity dropped to 3/60. By January 2015 the visual acuity had fallen further to counting fingers and treatment was discontinued. Subsequent investigation into the reasons for the delay in treatment between April 2014 and September 2014, identified a delay in cashing up a clinic, one patient initiated cancellation and one hospital initiated cancellation. Case 10. This patient was undergoing treatment with Lucentis for AMD in his better seeing right eye. A review appointment on the 22nd August 2014 indicated that further injections with Lucentis was required to the right eye and the intention was that the first of these injections would occur approximately 2 weeks later. The injection was given on the 18th October 2014 by which time the visual acuity had dropped from 6/60 to approximately 3/60. The visual acuity has subsequently declined to 1/60. Case 11. This patient he presented to the acute referral clinic with sub-macular haemorrhage in his better seeing right Ref: IRR00003 escalate a request for review to the consultant on-call if s/he has concerns. It is likely that the delay in treatment between April 2014 and September 2014 contributed to the deterioration of this patient’s vision to the point where further treatment is unlikely to be of benefit. The Trust has subsequently appointed a wed AMD coordinator who continues to have problems with capacity with treating patients with Wet Macular Degeneration. It is possible that a delay of 6 weeks in this patient’s treatment may have contributed to some reduction in visual acuity, although the patient’s visual acuity had already been relatively poor (6/60) for some time. On-going problems with capacity in Wet AMD treatment service was the main reason for the delay. The prognosis for haemorrhage of this type tends to be poor and although it is possible that the visual outcome might 9 eye. The patient was referred urgently to the medical retina clinic and an appointment was offered 14 days later. The patient was seen privately 12 days following presentation and referred back to the NHS where he was seen the following day. He had surgical procedure 6 days later. The opinion of the Consultant who saw him was that surgery should have been scheduled urgently at first presentation. Case 12. This patient with AMD was scheduled for a further injection of Lucentis on 10th September 2014 with the intention that the injection should be given within 2weeks but the injection was given on the 10th October 2014 at which time the patient was identified to have a submacular haemorrhage. The 2 week delay was felt to be important in the occurrence of this complication of macular Degeneration. Case 13. This patient presented with suspected Wet Macular Degeneration in September 2014 at which time the right visual acuity was 6/9. The patient was seen on the 22nd September by which time the right vision had declined to 6/18. A request was made for an urgent fluorescein angiogram. This was performed on the 6th October 2014 and reported on the 10th October 2014 at which time he was scheduled for three injections to the right eye, the first of which occurred on the 21st October 2014 by which time the right vision had declined to 1/60. Case 14. This patient was referred on the 22nd September 2014 with reduced vision in the left eye and the referral was triaged as urgent. The patient was seen on the 6th October 2014 and found to have a left full thickness macular hole with vision acuity of 3/60. The retinal Ref: IRR00003 have been better had surgery been performed earlier this is by no means certain. There is no nationally agreed guidance on timing of surgery under this situation and there was no local protocol covering this situation at the time although the department has subsequently developed one. It is possible that a delay of 2 weeks may have influenced the visual outcome of this situation. On-going problems with capacity in the macular service were the main cause of this incident. It is likely that the cumulative delays in treatment between the 22nd September 2014 and 21st October 2014 contributed to the decline of the patient’s vision from 6/9 to 1/60 and that the visual outcome may have been better had the first injection been given at the first appointment on the 22nd September 2014, subsequent investigation indicates that on-going issues with capacity in the AMD treatment service was the main reason for this delay. It is difficult to ascertain the length of time for which the macular hole had been present before presentation. The time delay from onset of symptoms to surgery is not particularly critical to the prognosis for visual improvement in cases of macular hole and it is unlikely that a delay 10 referral was made but the patient was not seen in the vitreoretinal clinic until 11th February 2015. The Consultant felt that this may have adversely affected the possible improvement in the vision of the left eye with macular hole surgery. Case 15. This patient was under review for glaucoma which was apparently well controlled and was being reviewed 6 monthly in a non-specialist glaucoma clinic. A visit in October 2014 took place in the Viewpoint clinic rather than in the usual glaucoma clinic and the pressures were found to be higher than at a previous visit but still within the normal range. The patient was referred back to the glaucoma clinic and was seen in February 2015 but significant progression of the condition was found to have occurred. Case 16. This patient with glaucoma was being seen in a general clinic from April 2012. A review was planned at 4 months following an appointment on the 31st August 2012, but the patient was not reviewed until Sept 2013 (a delay of 8 months) at which time the intraocular pressure was found to be poorly controlled. Treatment was changed and patient was planned to be reviewed in 2months but was seen in a Viewpoint clinic 3 months later. The right intraocular pressure was still higher than normal at 24mm but no further change in treatment was made. The pressure was unchanged in March 2014 and treatment was still unchanged. The patient was unable to attend in July 2014 because of other health problems and whilst attending a medical retina clinic in September 2014, the right intraocular pressure was further elevated at 30mm. The patient was referred to a glaucoma Ref: IRR00003 of 5 months in referral to a vitreoretinal clinic would have made any significant difference to the visual prognosis in this patient’s case. We do not feel that this should have been classified as a serious incident. There does not appear to have been any significant deviation from the planned management of this patient and there was no indication of any risk factors for rapid progression of glaucoma. It seems unlikely that a single review visit in the Viewpoint clinic was a contributing factor to the progression of this patient’s condition. We do not feel that this should have been classified as a serious incident. The Trust is currently reviewing the glaucoma service including the initial risk stratification of patients presenting with suspected glaucoma. There were a number of delays in follow up and referral for specialist opinion of this patient who clearly had poorly controlled intraocular pressure, and cumulatively these probably contributed to avoidable visual loss. Some of these delays were administrative but opportunities for more active intervention (particularly at the visits in December 2013 and March 2014) such as referral to a specialist glaucoma clinic were missed. 11 specialist clinic but appears to have been suspended for investigations awaiting instructions. The letter was triaged by the glaucoma consultant in January 2015 and the patient was seen in February 2015 by which time the right intraocular pressure was 42mm with evidence of advanced glaucoma with visual acuity of 6/18 in that eye. Retinal haemorrhage was also noted in the left eye. Case 17. This patient was diagnosed with glaucoma in February 2013 and was judged to be stable at that time but has been found to have progression of the condition in the right eye at the most recent review in May 2015. It was felt that lack of any documentation of gonioscopic at the first assessment may have resulted in earlier referral of this patient to a glaucoma specialist clinic. Ref: IRR00003 This investigation is ongoing and insufficient detail was provided to assess whether the progression of this patient’s condition was affected by the earlier management. 12 6. Reviewer Findings In 14 of 17 of serious incident reviews, the reported adverse event included a period where the patient was “lost to follow up” and / or instances of inability to offer an appointment within a clinically appropriate time frame. The consequences were as follows: In 6 cases (2,6,7,9,13 and 16), there was evidence of significant avoidable deterioration in vision. Three of these patients had “wet” macular degeneration and three had glaucoma. In case 7, it is likely that earlier treatment would have improved this patient’s visual prognosis, though the appointments offered by the Trust met the service standards required by the Commissioner. In 5 cases (1,3,10,11,12), there was possible evidence of avoidable deterioration in vision though the contribution of delays in the patient’s care to this is less clear, either because the prognosis for visual improvement was already poor or because of co-existing conditions which might have contributed to visual loss. One patient had a retinal vein occlusion and the remainder had “wet” macular degeneration. In 3 cases (4,14,15), there was no significant likelihood that the patient’s condition was affected adversely by the care they received and the reviewers do not consider that these should have been classified as serious incidents. In 2 of 17 serious incident reviews, there was evidence of sub-optimal clinical decisionmaking which may have resulted in avoidable visual deterioration. In case 8, it is possible that this patient with endophthalmitis would have had a better visual outcome had he been seen by an ophthalmologist on the day he presented to the urgent referral clinic rather than two days later. In case 16, there was evidence of inadequate intraocular pressure control in a patient with glaucoma at two successive follow up visits, but no steps appear to have been taken to address this. Administrative delays in subsequent referral to a consultant with a glaucoma interest also contributed to avoidable deterioration in vision. In two remaining serious incident reviews (cases 5 and 17), the information was not sufficiently detailed to allow the reviewers to assess whether avoidable deterioration in vision occurred. In the 12 cases (1,2,3,6,7,8,9,10,11,12,13 and 16) where there is probable or possible evidence of harm as a consequence of the care the patients received, the Root Cause Analysis accurately identifies the principal contributing factors and a number of Ref: IRR00003 13 measures have been put in place, or have been proposed, which will (if effectively implemented), substantially reduce the likelihood of similar occurrences in the future. This is discussed further below. An underlying cause which is common to all these 12 cases (with the possible exception of case 8) is a mismatch between capacity and demand in the ophthalmology service, a problem which afflicts almost every ophthalmology service in the UK to a greater or lesser extent. Macular degeneration treatment services and glaucoma services are particularly vulnerable to these pressures, the former because of narrow time-windows for successful treatment and the latter because of the need for lifelong monitoring of most patients. A factor which contributes to the capacity shortfall is the fact that the current estate is too small for current needs and will need to expand to meet current and predictable future service demands. This, together with new ways of working and diversification of the workforce will provide additional safeguards against further similar adverse events. Is the apparently large number of serious incident declarations in the ophthalmology service at SATH a reflection of an unusually high number of serious incidents or is it a reflection of an active culture of reporting and learning in the organisation? This is a difficult question to answer because it is likely that there is variation from one Trust to another in terms of the threshold at which a serious incident is declared. As discussed below, SATH has a strong commitment to reporting and learning from adverse events and to the Duty of Candour. The adverse events described above are similar in nature to events reported in other ophthalmology services in the UK and, although it is not possible to estimate the “average” incidence of similar adverse events, the reviewers feel that SATH is probably comparable with other ophthalmology services of similar size in this regard. 7. Ophthalmology Services at SATH The ophthalmology service at SATH serves a population of 544,000, of which 308,000 live in Shropshire, 168,000 in Telford area and 68,000 in North Powys. Services are provided at the Royal Shrewsbury Hospital (outpatients, adult day case and inpatient surgery, emergency eye care), Princess Royal Hospital Telford (outpatients, paediatric surgery) and Wrekin Community Clinic in Telford (outpatients, day case cataract surgery). Peripheral clinics are undertaken in Whitchurch and Welshpool. Since the service relocated from a small ophthalmic / ENT hospital in the centre of Shrewsbury to the RSH site in 1998, it has expanded considerably in terms of staffing and the number of patients seen per year. A substantial factor in the expansion of services has been the advent of effective treatments for neovascular (“wet”) age-related macular degeneration. Ref: IRR00003 14 There are currently 10 consultant ophthalmologists with sub-specialty interests as follows: medical retina (3), vitreoretinal surgery (2), oculoplastics (2), paediatrics / squint (1), glaucoma (1), cornea (1). The service is supported by 7 specialty doctors and 5 Specialty Registrars from the West Midlands specialty training scheme. The department has 7 WTE orthoptists who, in addition to providing orthoptic support to the hospital clinics, undertake primary vision screening of children at school entry in a number of locations across Shropshire and Powys. Optometrists provide refraction, contact lens and low vision services to support the hospital clinics on a sessional basis. Ophthalmic imaging support is provided by SATH’s clinical photography department. In 2014-15, the ophthalmology service had 49,274 outpatient attendances, of which 7970 were for patients under 17 and 28,702 were for patients aged 65 or over. There were 3611 inpatient or daycase episodes in the same period. Senior members of the department noted that, for at least the last 20 years, the ophthalmology service has more or less continuously been reliant on additional clinical activity beyond normal timetabled sessions to keep pace with demand, even though the consultant numbers have doubled in that time. Members of the department frequently undertake clinics or intravitreal injection lists beyond their normal clinics. In addition, NHS patients can opt to have cataract surgery at the Nuffield Hospital, where SATH consultants perform the surgery. SATH has engaged Viewpoint (a company which employs a number of consultant ophthalmologists from outside the immediate area) to undertake additional outpatient clinics at weekends on a regular basis. Shropshire CCG has initiated a community-based secondary screening service using community optometrists for children who are found to have reduced vision on primary school-entry vision screening. Despite these activities, it remains a constant challenge for the ophthalmology service to offer new and follow up appointments and outpatient treatments within required time-frames, and this reflected in the nature of the Serious Incidents reported. Although all of the sub-specialty and general ophthalmology services are busy, particular challenges are faced by the macular treatment service and the glaucoma service. Agerelated macular degeneration (AMD) is common and becomes increasingly common with advancing age. About 10% of patients with AMD develop the more rapidly progressive neovascular or “wet” form which, untreated often results in severe loss of central vision. Treatment with antibodies to vascular endothelial growth factor (VEGF), such as ranibizumab (Lucentis) and aflibercept (Eylea) is effective in stabilising or even improving vision, but can only currently be delivered by intravitreal injection. Where diagnosis and treatment is delayed, the condition can progress rapidly to the point where visual loss becomes irreversible. The condition is prone to relapse and treatment may need to continue at monthly or two monthly intervals for prolonged periods to maintain visual acuity. The challenge of keeping up with demand in an AMD service Ref: IRR00003 15 results from the combination of the numbers of patients presenting with wet AMD and the exacting treatment schedule to prevent visual loss. It is proving to be an enormous challenge for ophthalmology services across the UK because of its heavy demands on staffing and space, and for the wider health economy because of the high cost of the drug and its administration. The prevalence of glaucoma is about 2% in adults over the age of 45, but rises to around 8% over the age of 75. Its onset is usually insidious and its progress undetectable to the sufferer. Visual loss from glaucoma is irreversible and can at worst be total, so the aim of treatment is to reduce intraocular pressure and maintain it at a sufficiently low level that any further decline in optic nerve function does not exceed that which occurs naturally with age. Although most glaucoma sufferers require relatively infrequent monitoring (typically 6 monthly) and their condition can be controlled with eye drops, stability in glaucoma can never be taken for granted and lifelong monitoring is essential. A minority of patients have brittle or unstable glaucoma where more frequent monitoring or additional interventions may be required to prevent visual loss. The challenge of keeping up with demand in glaucoma services results mainly from the numbers of patients with the condition and the effect of increasing numbers of very elderly people in the population. The fact that most glaucoma patients require relatively infrequent appointment also makes the glaucoma service vulnerable to pressures on follow up appointments when other parts of the ophthalmology service are stretched. Ophthalmology services across the UK have responded to the challenges of rapidly increasing demand in a number of ways, for example: Increasing productivity: streamlining processes so that more treatment can be given by the same number of people in the same time. This has been particularly successful in cataract surgery services for example Training non-medical personnel to undertake tasks formerly only performed by ophthalmologists: examples include nurse-led triage and treat for urgent eye conditions, nurse led ophthalmology sub-specialty clinics, nurse-led intravitreal injection lists. “Virtual” clinics, where a senior clinician makes management decisions remotely, or off-line, based on measurements taken by other healthcare professionals “One stop” clinics where a number of assessments or interventions are combined into a single visit Shared management of some categories of patients with community optometrists All of these service innovations have, when implemented well, demonstrated clear benefits to the quality and safety of care for patients. However, choosing the best and most cost-effective model for delivery of care for a particular locality requires careful Ref: IRR00003 16 consideration of a range of factors including population characteristics, geography, transport links, the available workforce and the natural history of the conditions for which care is being provided. A further peculiarity of ophthalmology services is that they invariably have a heavy footprint in terms of floor area. The reasons for this include heavy reliance on bulky equipment, very high patient throughput, and the need for substantial waiting areas (because the majority of patients are elderly or require dilating drops and are therefore accompanied by friends or relatives, and also often require additional tests as part of a consultation). Macular Service – Progress and Constraints As a response to the Serious Incidents relating to delayed treatment in patients with wet AMD, SATH has appointed a coordinator and “failsafe clerk” for the macular service who maintains a database of patients receiving intravitreal injections. This helps to ensure that treatment schedules are coordinated, review appointments are made, and fulfils a failsafe function. This has substantially reduced the risk of patients becoming lost to follow up. The department has plans to introduce a “one-stop” macular clinic so that the decision to treat and the treatment take place at the same visit, allowing flexibility in treatment schedules. Despite the work of the AMD coordinator, the service often runs 2-3 weeks behind intended assessment and treatment schedules because of pressure on clinics and injection lists. It has not been possible to implement a one-stop intravitreal treatment service because the SATH pharmacy will not currently permit intravitreal medicines to be dispensed without a named-patient prescription. The macular service at RSH is severely constrained by lack of space. Even when doctors are available to undertake additional injection lists, there may be no room for the list to take place. Although some injection lists take place in Telford, patients from West Shropshire and Powys are generally unwilling to travel to Telford. Intravitreal injection lists are currently all undertaken by ophthalmologists, particularly by the specialty doctors and approximately 60 injections per week are given. Recruitment to the specialty doctor grade is becoming increasingly difficult nationally. Intravitreal therapy with ranibizumab has also been approved by NICE for diabetic macular oedema and retinal vein occlusions, increasing the workload even further. Imaging facilities also limit the capacity of the service, particularly at RSH. There is a one OCT scanner at RSH, one at PRH and one at Wrekin Community Clinic. One photographer from the Trust’s clinical photography service provides support for fluorescein angiography in Shrewsbury and Telford. Several members of staff have been trained to use the OCT scanners. The OCT is currently situated in a room used for other functions due to lack of space. This can lead to a bottle-neck and delay patients in their management pathway. Ref: IRR00003 17 Glaucoma Service – Progress and Constraints As a response to the Serious Incidents relating to delayed treatment in patients with glaucoma, SATH has put in place additional measures to monitor regularly the numbers of patients who are overdue for follow up appointments. It has also engaged Viewpoint, a company which employs a number of consultant ophthalmologists, to undertake additional clinics at weekends. Despite these measures, the Patient Access Booking Team finds it a constant challenge to allocate follow up appointments for patients with glaucoma because of the large numbers. The service is also currently compromised by the fact that the department’s only consultant with a sub-specialty interest in glaucoma is not currently working. The effect of this on the care of patients with unstable or complex glaucoma is a matter of concern. Paediatric Ophthalmology Service – Progress and Constraints Although none of the reported Serious Incidents related to the paediatric ophthalmology service, a number of members of the department commented that this service is very busy and works under considerable pressure. Shropshire CCG has recently launched an initiative for community optometrists to undertake secondary screening of children who fail the school-entry sight test, so that children with normal fundi and simple refractive error are not automatically referred to the hospital eye service. Whilst this has relieved the burden of new referrals to some extent, it has been observed that communication back to the orthoptists is patchy at best, and that fewer than expected children are being referred back to the hospital eye service, raising a concern that amblyopia or other eye problems may be under-recognized in the secondary screening tier. Cataract Service A cluster of “Never Events” relating to intraocular lens insertion during cataract surgery occurred in 2011-12 which was the subject of an earlier College invited review. A number of changes to the processes for selecting and verifying intraocular lenses were put in place as a result and no further Never Events have occurred since that time. None of the 17 Serious Incidents reviewed relate to the cataract service. Cataract surgery takes place at RSH and Wrekin Community Clinic. It is generally acknowledged that the lists at Wrekin Community Clinic achieve consistently higher throughput than those at RSH. Diabetic Retinopathy Screening and Treatment The Diabetic Eye Screening Programme for Shropshire is based in the Hummingbird Centre on the RSH site and covers a diabetic population of about 24,000 with a combination of fixed and mobile cameras. Mr Sardar is the Clinical Lead for the Ref: IRR00003 18 programme and a number of the Specialty Doctors are Referral Outcome Graders for the programme. The service meets its targets in terms of access to ophthalmology appointments and laser treatment. The ophthalmologists can view retinal screening images from the ophthalmology clinic rooms. It is generally acknowledged that this service functions well. Urgent and Unscheduled Care The eye department does not have a walk-in eye casualty service, but instead runs a booked urgent care service which takes referrals from A&E, GPs and optometrists which operates during normal working hours. The service is staffed by nurse practitioners who undertake triage, and ophthalmology specialty doctors or registrars. There is a two-tier on call service with registrars and specialty doctors forming the first on-call tier and consultants providing the second tier. It is sometimes necessary to travel to PRH when on call to see urgent inpatient referrals, though where possible, these are accommodated in clinics at PRH during the day. The urgent care service (as is invariably the case in other areas) is busy. Other Sub-Specialty Services No significant issues (beyond the general observation that all clinics are busy) were raised with the reviewers relating to the vitreoretinal, corneal or oculoplastic services. Community eye care services An Eye Care Working Group is established across the Local Health Economy. The group meets quarterly with representatives from all Provider agencies, Shropshire and Telford & Wrekin CCGs, GP practices, the voluntary sector and Local Authority. In addition to this, the Provider Agencies and CCGs meet on a monthly basis as a smaller group to develop specific pathways to support delivery of RTT in Ophthalmology Services across the county. Over the past two years the Eye Care Working Groups (ECWG) has developed and introduced several schemes to support patient access into Ophthalmology Services (See Appendix 1). Schemes aiming to reduce referrals to hospital include a repeat measurement scheme for suspected glaucoma, a cataract referral refinement scheme, an urgent primary eye care scheme and a secondary screening scheme for children who fail school-entry vision screening. The Practice has been contracted to triage incoming referrals to ophthalmology and treat cases it judges to be suitable. Schemes which aim to facilitate discharge from the hospital eye service include a cataract postoperative follow up scheme, and two schemes for monitoring of patients with ocular hypertension and low-complexity glaucoma. The commissioners are keen for the community services to be used to a greater extent (see Shorpshire CCG’s comments in Appendix 1). Ref: IRR00003 19 8. Management and Governance The ophthalmology service sits within a wider group of Head and Neck services. The Clinical Director, Mr Stuart Thompson, is an ENT surgeon and has recently taken up this leadership role. Mr Robert Dapling is the Lead Clinician for Ophthalmology. The Head and Neck division has its own Matron (Fiona Gabbitas) and Centre Manager (Lisa Challinor) as well as a dedicated Patient Access team led by Janine McDonnell. The senior ophthalmic nurse for the RSH is Jenny Bridges and Marie-Claire Wigley is her opposite number for the PRH and WCC sites. The reviewers heard from the Executive Team members that the ophthalmology service had been through some very difficult times in the last few years. There had been a number of contributing factors, but the Never Events in the cataract service in 2011-12 had contributed to a particularly traumatic time for the ophthalmology team. It was acknowledged that mistakes had been made in the way that this was handled by the Trust at the time. The Executive Team members said that it was the Trust’s aim to provide better support to the ophthalmology service than had been the case in the past, and the current leadership structure reflected that commitment. This was acknowledged by the consultants who paid tribute to their nursing colleagues and the departmental management team. The reviewers were impressed by the Trust’s commitment to patient safety and the Duty of Candour. Reporting of safety concerns is actively encouraged and there is a well-documented process for root-cause analysis, learning points, actions and the discussion held with the patient involved. Brenda Maxton, the Trust’s Patient Safety Advisor is responsible for ensuring that there is a consistent process for reporting and discussing safety concerns, and for providing training and support to the Clinical Governance leads in each department. For the ophthalmologists, the journey to a culture of reporting and learning from patient safety concerns has not been an easy one and their experience has been coloured by the “never events” of 2011-12 which they describe as having been handled in a heavy-handed and punitive way. To heal the wounds of the past will take some further work but reviewers are confident that the clinicians and the management team are actively committed to working through the issues. 9. Workforce Planning The ophthalmology service has a traditional structure for its medical workforce with 10 consultants serving a population of around 540,000 supported by a middle tier of specialty doctors which contributes to the urgent care service and the first on-call rota, and 5 specialty registrars. The subspecialty interests of the consultants are broadly Ref: IRR00003 20 appropriate to a population of this size, though it is unusual to have a single-handed glaucoma service. Recruitment at consultant level in ophthalmology nationally is generally good, though some sub-specialties (particularly paediatric ophthalmology) have struggled to recruit at times and posts in more remote areas of the UK or posts where the job plan is regarded as unattractive may fail to attract suitable applicants. There is an impending crisis in the Specialty Doctor grade nationally as a result of expansion in services as a result of the introduction of run-through training and changes in UK visa regulations around 2007. The numbers of new entrants to this grade is small and the numbers of existing doctors in this grade is likely to fall precipitously in the next few years because of retirements. Many ophthalmology services are replacing Specialty Doctor and Associate Specialist retirement vacancies with consultant posts or are investing the money in specialist nurses or other practitioners. The most immediate impact of this demographic change will be on the ability to staff EWTD-compliant rotas for urgent care out of hours. This is likely to result in an increasing need to train non-ophthalmologists to undertake triage and treatment of urgent eye problems. Ophthalmic nursing is an attractive career path because it is generally compatible with family-friendly work patterns and offers many opportunities to develop extended skills. Recruitment and retention of ophthalmic nurses nationally is patchy, but is likely to be good where the Trust has a commitment to nurse training with links to a university nursing course and where the ophthalmology department has a strong training ethos. Recruitment and retention in orthoptics was very difficult a few years ago but has improved somewhat as the two undergraduate courses at Sheffield and Liverpool have expanded. It is usually possible to recruit to full time posts, but part time posts can be very hard to fill. Optometrists make a substantial contribution to the ophthalmic workforce in some areas, either by participating in shared care services, by contributing hospital sessions or by direct employment by hospital eye departments. Around 10,000 optometrists graduate each year in the UK, most of whom will work in community optometric practice. Shropshire is an attractive area for optometric practice and it may be possible to work with local optometrists to develop post-registration training opportunities for optometrists as a joint venture with the hospital eye service. 10. Estate and Facilities There are significant problems with the physical environment of the ophthalmology service which have almost certainly contributed to the occurrence of the Serious Incidents reviewed. Currently the ophthalmology service at RSH is based in Ward 10, which as intended to be temporary accommodation when the old eye hospital was closed in 1998. Since that time, demands on the service have increased greatly, Ref: IRR00003 21 particularly as effective treatments for AMD have been introduced. In addition to its dated appearance, Ward 10 is very cramped with several rooms serving dual functions as clinical areas and equipment storage areas. Equipment frequently has to be moved between sessions and it is very difficult to achieve an efficient “patient journey” through a visit which includes vision testing, diagnostic tests, a clinical consultation and perhaps an outpatient procedure. This inevitably has a deleterious effect on waiting times and patient experience, not helped by a shortage of space for seating for patients and accompanying persons. The cramped conditions make very difficult to maintain a satisfactory level of privacy. There is a particular need for dedicated accommodation for patients needing intravitreal injections, not only to ensure efficient throughput, but also to ensure that intravitreal injections can be carried out in conditions which reliably meet relevant infection control standards. The Trust has produced detailed plans and a full business case for relocation of the ophthalmology service to the former Antenatal Clinic and adjacent Ward 17 at RSH. The reviewers viewed this area and believe that, with appropriate refurbishment, it would form very suitable accommodation for the current and predictable future needs of the ophthalmology service. The basic fabric of the proposed accommodation is generally good, the layout would not require complex adaptation and it represents a considerable increase in total floor space. The reviewers made some suggestions for minor changes to the plans, but the plans had clearly been drawn up with considerable care and with adequate clinical input. The reviewers believe that the proposed relocation of the service would considerably assist other initiatives to improve the quality and safety of the service, would improve patient experience and would improve the morale of the workforce, which is of clear relevance to recruitment and retention of staff. 11. Summary The reviewers were impressed by the enthusiasm and commitment of the members of the ophthalmology service and their vision for the future of the service. Although department has been through some very difficult times, there is a clear desire to move on and work together to improve the Ophthalmology service for patients. It is a particular strength of the department that it has an enthusiastic leadership team encompassing medical, nursing and managerial staff with a clear focus on improving the service and clear lines of accountability. It is also clear that the current Executive team understands the challenges facing the ophthalmology service and is similarly keen to see it succeed. The response to the Serious Incidents has been determined and constructive and a number of measures have already been put in place which are likely to reduce the likelihood of similar events occurring. Formal Root Cause Analysis methodology is Ref: IRR00003 22 employed and there is a standard template for documentation of the investigation, resulting action plan and discharge of the Duty of Candour. A positive outcome of the SI investigations has been the creation of a Failsafe Clerk/ Coordinator post for the Macular Degeneration Service. The Failsafe Coordinator has set up a database that allows improved monitoring of referral to treatment time, scheduling of treatment and follow up visits and rescheduling following missed appointments. The Trust operates a partial-booking process for review outpatient appointments whereby appointments intervals of 6 weeks or less are booked immediately and appointment intervals of more than 6 weeks are placed on a pending list to be booked around 6 weeks before the intended appointment interval. Compared with a system where all follow up appointments are allocated at the time they are requested, a partialbooking process has the advantage that it minimises the need for hospital-initiated cancellations resulting from notifications of staff leave. However, in the context of a service which has significant under-capacity, there is a substantial risk that a very large backlog of patients who are overdue for review can build up in a relatively short time. There is a further risk that patients may then be lost to follow up. Patients with long term conditions such as glaucoma are particularly vulnerable to this situation and there have been a number of well-documented examples in other areas of the country of patients with glaucoma losing vision as a result of loss to follow up or slippage of intended follow up intervals. Although the reviewers believe that the use of a partial booking system for ophthalmology review appointments still presents a risk in the context of the underlying capacity problems, they were reassured by evidence that the performance of the service is monitored at 2 weekly intervals, that the metrics used for this are appropriate, and that the process has clinical input. The Trust has also put into place an automated telephone reminder system for appointments which has reduced the “Did Not Attend” (DNA) rate from 8% to 5.5%. The performance of the ophthalmology service is significantly hampered by its physical environment. The service has expanded considerably in the last few years to accommodate the macular treatment service and the existing accommodation on Ward 10 at RSH is no longer fit for purpose. The consultants feel that the dispersion of the service between PRH and Wrekin Community Clinic in Telford is disadvantageous to efficient working, though space is not a major issue. The favoured proposal to refurbish the former antenatal clinic and Ward 17 at the RSH for ophthalmology requires capital funding, but the reviewers believe that it would greatly improve the ophthalmology service and would accommodate current and predictable future needs of the service. It would also considerably assist training and workforce development. Shropshire CCG has raised the question of whether it would be possible to deliver more ophthalmology services outside the hospital with a greater range of providers. Although Ref: IRR00003 23 there is some scope for this for medium and long term service planning, major investment in infrastructure and training would be required given the very large numbers of patients who require ongoing care. Even where the aim is to supplement, rather than to replace capacity in the hospital eye service, it is unusual to be able to identify significant spare capacity in existing community services (e.g. community optometric practice, community health centres, GP surgeries) which would permit the care of substantial cohorts of patients to be diverted in the short term. Experience from other areas suggests that providing and equipping suitable premises is often a timeconsuming and costly undertaking. With these caveats, there may, however be scope to develop a multidisciplinary, shared care model for glaucoma, providing that there is a facility for sharing care records and a similar failsafe system to that which underpins the diabetic eye screening service. However, this is predicated on consultant leadership of the glaucoma service. The SATH ophthalmology service already has an electronic clinical record (Medisoft), and although this is not yet used to record all ophthalmology consultations, lays the foundation for shared care. Community optometrists are already contributing to secondary screening of children who fail the school-entry sight test (See Appendix 1). Although this model of care works well in a number of other areas of the country, the reviewers were concerned to hear that there does not appear to be a clear system for tracking the progress of children who enter secondary screening to ensure that, where the reason for reduced vision is more than simple refractive error (e.g. amblyopia, physical abnormalities of the visual system), appropriate and timely onward referral is made to the hospital orthoptic service or a paediatric ophthalmologist. The treatment of macular degeneration is inevitably labour-intensive and requires a highly coordinated service. Although there has already been significant investment in the development of the nursing workforce by SATH, with advanced nurse practitioners in the cataract, glaucoma, oculoplastic and retinal services, foreseeable problems with future recruitment of specialty doctors means that a logical development for the macular treatment service is to train a cohort of nurse practitioners to deliver intravitreal therapy. The development of a one-stop AMD treatment service will necessitate a change in the system for prescribing and dispensing ranibizumab or aflibercept so that the decision to treat and the delivery of treatment can be made at the same consultation. This may be facilitated by input from another service which already runs this type of service. The ophthalmology department will continue to be challenged by the numbers of people requiring its services. As a further safeguard against similar Significant Incidents to those reported, further work on population modelling and capacity planning needs to be undertaken jointly between SATH and Shropshire and Telford CCGs. Ref: IRR00003 24 There may be opportunities to develop a clinical research component to the ophthalmology service. Links could be developed with local universities such as Keele or Staffordshire. The development of a research portfolio could improve recruitment by increasing the attractiveness of posts. Research funding can also provide direct benefit to patient care via investment in equipment, staffing or other aspects of infrastructure. Patients rightly expect a clinical service which is responsive, effective, safe and compassionate whoever is providing it and wherever it is provided. However, experience has shown that ophthalmology patients also value stability, familiarity and the ability to build durable partnerships with the clinicians who contribute to their care. We suggest that these factors should underpin discussions about future service provision. Ref: IRR00003 25 12. Recommendations 1. SATH should work together with Shropshire and Telford CCGs on population modelling and capacity planning in ophthalmology, particularly for macular treatment, glaucoma and childrens’ eye services, so that appropriate provision can be made for predictable demand in terms of workforce, appointments and facilities. This could pave the way for a greater proportion of care to take place outside the hospital and diversity of providers, where appropriate, but there must be appropriate safeguards to ensure that patients are managed in an environment appropriate to the complexity of their clinical condition by appropriately trained staff, and to ensure reliable and safe handover of care. 2. The cramped facilities at RSH probably represent the single largest obstacle to further work to improve the ophthalmology service in Shropshire. The Trust’s proposal to refurbish the former antenatal clinic and Ward 17 at RSH would transform the service, paving the way for all the service improvements discussed above but shortage of capital is a significant problem. This represents an important opportunity to safeguard quality and safety of care, improve patient experience, facilitate training and multi-disciplinary working, and improve workforce recruitment / retention. We suggest that a joint approach by the Trust and Shropshire CCG to the Trust Development Agency for help with this initiative should be considered. 3. A failsafe database should be established for patients with glaucoma, suspect glaucoma and ocular hypertension covering all providers. This would provide an important safeguard against avoidable sight loss due to loss to follow up or delayed follow up. This is particularly important if Shropshire CCG’s desire for a greater proportion of patients with low-complexity glaucoma and ocular hypertension to be managed (or co-managed) in a community setting is to be realized. As noted above, the long-term stability of glaucoma can never be assured and there must be a reliable mechanism for instability to be recognized and care escalated promptly to a glaucoma specialist when required. Shropshire CCG could either choose to host such a failsafe database itself, or delegate this task to SATH. 4. Current lack of consultant leadership for the glaucoma service presents an immediate clinical risk, particularly for patients with complex or unstable glaucoma. This needs to be addressed as a matter of priority. 5. SATH should move forward with plans for a one-stop AMD treatment service and the training of nurse practitioners to deliver intravitreal therapy. We have provided contact details to Fiona Gabbitas of an experienced ophthalmic pharmacist who will Ref: IRR00003 26 be happy to advise on safe procedures for the dispensing and administration of intravitreal medications in a one-stop setting. 6. Shropshire CCG should work with the orthoptic service based at SATH to ensure that outcomes of referrals from school-entry sight testing to the community optometristled secondary vision screening service are audited and quality assured. 7. SATH should undertake a review of anticipated ophthalmic workforce needs, taking account of forthcoming retirements and predictable issues with recruitment described above. This should consider the balance of sub-specialty interests required, and, in particular should aim to reduce dependence on the specialty doctor grade to support the future clinical service. Such a review should inform plans to develop further the role of nurse practitioners, orthoptists, optometrists and ophthalmic technicians. 8. SATH should continue to build on its commendable work on safety of patient care. A possible improvement relevant to the ophthalmology service would be to raise the professional status of the departmental clinical governance lead role by providing appropriate induction and training and a peer-support network, with appropriate SPA (or equivalent) recognition in job plans. This will empower clinical services to take ownership of clinical risk and safeguards in their area and provide a powerful tool for learning from adverse events. This will provide the CCG with a greater level of assurance that the service has a culture of open reporting, risk reduction and shared learning. 9. A successful culture of reporting and learning from clinical safety issues also needs to be a low-blame culture. There is a perception amongst the consultants that the Trust is still too ready to blame doctors when things go wrong. Although this view is undoubtedly coloured by the fall-out from the “never events” of 2011-12 and the mistakes in the Trust’s response made at that time have been acknowledged by the current Executive team, there is still work to be done to rebuild trust and to ensure that the response to adverse events is, and is seen to be fair and proportionate. 10. Although the ophthalmology service has made good progress towards electronic clinical record-keeping, SATH should encourage and facilitate its wider adoption in ophthalmology, with the aim that the whole ophthalmic record for each patient should be available in electronic format. 11. Improved integration between primary and secondary care requires the ability of all providers to share person identifiable information securely. As a minimum this requires access to NHS.NET accounts. For optometric practices, this requires completion of the HSCIC Information Governance Toolkit to Level 2, which has some Ref: IRR00003 27 cost implication, but could be facilitated by the CCG with input from Local Optometric Committees. However, there could be considerable future benefits in the form of electronic referral and shared care initiatives. Richard Smith Bernard Chang September 2015 Ref: IRR00003 28 Appendix 1 – Schemes implemented by the Eye Care Working Group November 2012 to September 2014 Scheme Glaucoma Repeat Pressures PEARS (Primary Eye Care Assessment and Referral Service) Post Operative Cataract Follow Up Implemented November 2012 Delivered by Community Optometrists Community Optometrists Shropshire CCG Comments The scheme aims to reduce new out patient referrals to secondary care by repeating measures in community optometry practices The scheme provides rapid access to eye care services for a range of conditions (red eye etc) to reduce activity within urgent ophthalmology services January 2014 Community Optometrists Cataract Referral Refinement Scheme Ocular Hypertension Monitoring September 2014 Community Optometrists October 2014 Community Optometrists Paediatric Screening Pathway September 2014 Community Optometrists In addition: A community ophthalmology service has been set up, delivered by The Practice Stable Glaucoma December 2013 The Practice SaTH to ensure all patients who have had cataract surgery and anticipated to have no complications will be followed up by Community Optometrists Community Optometrists to provide pre referral screening to include quality of life review for patients who require cataract surgery SaTH to identify all those patients with OHT who are suitable for transfer to be followed up within Community Optometry practices – SaTH have not been discharging patients onto this pathway. This has been escalated internally due to the service being developed to support capacity for those patients who require secondary care services Follow up in community optometry practices for those children who fail school screening. SaTH had reported a high incidence of these children not being seen but it would appear they had also been referring patients who had “just passed” the screening. Follow up of those who have not attended is being undertaken by the Referral Assessment Team at the CCG to encourage attendance. In addition, those children who fail the screening and require hospital attendance are being asked to attend the Optometrist first for Cycloplegic refraction testing to avoid them attending the hospital more often than necessary To receive all referrals for general ophthalmology, glaucoma and minor operations within the community service. These are then triaged and those suitable to be treated in community services remain with The Practice and those not suitable are referred to secondary care. September 2014 The Practice Ref: IRR00003 July 2013 A new pathway to ensure all those patients with stable glaucoma at SaTH who are “stable” can be referred to The Practice for future follow-up thereby releasing capacity in Secondary Care. As with OHT, SaTH have not been discharging patients onto this pathway, despite repeated requests. This is slowing happening over recent months. 29