Download The Royal College of Ophthalmologists INVITED SERVICE REVIEW

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
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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
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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
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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
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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
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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.
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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.
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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