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Commissioning Guide Service Model Examples
Stockport IOP Refinement Service
Enhanced Service Description
The IOP repeat measures pathway
allows community optometrists to
improve the accuracy of referrals by
repeating IOP measurements using
Goldmann style tonometers to
confirm the risk of Ocular
Hypertension or COAG in patients
who are found to have IOP >
21mmHg at a routine sight test.
LOC Lead: Trevor Warburton
Service Aims
1. To achieve cost savings by
reducing unnecessary
referrals to the hospital eye
service.
2. To increase capacity within
hospital glaucoma clinics.
3. To provide care closer to
home at a convenient time
and location for patients
4. To manage more patients in
a primary care setting
5. To reduce patient anxiety
linked to hospital referrals
6. To demonstrate innovative
utilisation of the available
skilled work force to provide
patient centred care
Cost Benefits
The data collected from the first 6 months of the
Stockport service shows that 311 people have
accessed the enhanced service, with 60% of patients
being discharged after first IOP repeat, and a further
17% being discharged after 2nd IOP repeat.
Therefore, a total of 77% of potential ophthalmology
referrals have been deflected by the IOP repeat
measures service.
Assuming 650 patients access the service in a 12
month period:
Total IOP repeat measures costs = £42k
(£14k optometrist fees + £10k IT + £18k secondary
care)
Total secondary care costs = £80k
(if all patients were referred)
Annual Cost Savings = £38k (population 300,000)
Hereford Cataract Referral Refinement & Post- Op Service
Enhanced Service Description
Service Aims
The Cataract Referral
1. To reduce unnecessary
Refinement Pathway allows
referrals to secondary care
community optometrists to
ophthalmology clinics
reduce unnecessary referrals by
2. To release capacity in
using extra tests to ensure that
secondary care clinics by the
the eye is suitable and ready for
reduction in referrals and
surgery, and counselling the
providing follow up in the
patient on the risks and benefits
community
of the operation to determine
3. To provide a more patient
whether he or she wishes to
centred pathway with fewer
proceed with surgery if deemed
visits for the patient
appropriate by the
4. To provide care closer to
ophthalmologist. The optometrist
home at a convenient time
refers directly to the Eye Unit
and location for patients
when referral is agreed.
5. To manage more patients in
Following surgery the patient is
a primary care setting
referred back to the community
6. To reduce patient anxiety
optometrist for assessment
linked to unnecessary
rather than have to make further
hospital visits
visits to the hospital.
7. To demonstrate innovative
utilisation of the available
skilled work force to provide
patient centred care
LOC Lead: Peter Bishop
Cost Benefits
The key benefits of the cataract pathway are in patient
centred care and releasing capacity in secondary care,
whilst remaining cost effective.
Local audit shows that before referral refinement was
implemented, 65% of patients referred for cataract were
listed for surgery, whereas 95% of patients referred for
cataract in 2010 went on to have surgery.
450 patients were referred for cataract in 2010 including
5% false positives. The reduction in false positives of
30% compared to before the pathway was implemented
equates to a total of 200 patients, which at £124 new
patient tariff (2010) equals £24,800. 650 patients were
seen by community optometrists for Cataract Referral
Refinement in 2010 at a cost of £26,000.
750 patients were seen for post op follow up by
community optometrists in 2010 at a cost of £22,500. If
these patients were seen in secondary care the cost
would be £50,250 based on follow up tariff of £67 (2010).
The number of post op patients is higher than the surgery
figure due to some patients having surgery out of area
and the fact that some GPs continue to refer cataracts
without patients seeing the optometrist first.
Total Cost of Primary Care Service = £48,500
Total Cost of Secondary Care Service = £75,050
Annual Cost Savings = £26,550 (population 180,000)
Somerset Acute Community Eyecare Service (ACES)
Enhanced Service
Description
The Somerset ACES pathway
allows patients experiencing
a recent eye problem such as
reduced vision, red or painful
eyes, flashes and floaters,
double vision or watering of
the eye to be assessed and
managed where appropriate,
by community optometrists (in
29 different practices across
Somerset) as opposed to
being referred to the hospital
eye service. Patients can be
referred by their GP or selfrefer. Where referral to
secondary care is required it
will be to the appropriate
specialist with suitable
urgency.
LOC Lead: Sarah Farrant
Service Aims
1. To achieve cost savings by
reducing unnecessary
referrals to the hospital eye
service
2. To release capacity in
secondary care clinics by
the reduction in referrals and
associated follow ups
3. To provide care closer to
home at a convenient time
and location for patients
4. To provide a more patient
centred pathway with
increased choice of provider
5. To manage more patients in
a primary care setting
6. To demonstrate innovative
utilisation of the available
skilled work force to provide
patient centred care in the
community
Cost Benefits
Local audit of activity between July 2009 and November
2010 showed that an average of 400 patients per month
were seen under the scheme. Of those, 75% of patients
were managed by the community optometrists (including 9%
who required a follow up appointment), with only 25% of
patients being referred to secondary care.
Assuming 4800 patients access the service per year
(population :
Total cost of ACES = £401,760
£252,960 (optometrists fees) + £148,800 (secondary care)
Total cost if all patients were referred to secondary care =
£624,144
Annual Cost Savings = £222,384 (population 460,000)
West Kent Community Ophthalmology Team
Enhanced Service Description
A team of optometrists with a special interest
(OPwSIs) and one GPwSI see patients in a
variety of settings: either in community
optometric practice, in the hospital or in rented
rooms away from the commercial environment of
an optometric practice.
All ophthalmology referrals except paediatrics
and AMD go via the Primary Care Booking
Service (PCBS) where they are paper triaged by
one of the COT to determine whether it is
appropriate to see them in the community or if
need a consultant appointment. The reasons for
them being seen in the community are either that
the referral does not contain sufficient
information to enable a judgement to be made as
to the appropriateness of the referral or that the
referral is for a list of conditions that are deemed
suitable for community assessment. These
would include suspect OHT and minor eye
problems that the OPwSI or GPwSI could see
and treat. The patient is then contacted by the
PCBS to offer them an appropriate appointment.
If appropriate, COT members working under the
supervision of a consultant ophthalmologist also
manage patients with stable or suspect
glaucoma or OHT.
Lead: John Nester
Service Aims
1. To offer more convenient
access to patients.
2. To enable the hospital to
see patients who needed to
be seen by the hospital
rather than dealing with
minor or stable conditions
which could be appropriately
managed in primary care.
Cost Benefits
Total No. news:
Glaucoma news:
Total discharge at first
appt to hospital:
1486
833
Total No. follow-ups:
Glaucoma follow-ups:
272
160
273
Total cost of COT
(exc. The GPwSI) £188,415.56
3. To save money.
Secondary care cost (£)
New appt
124 184,264.00
Follow-up
67 18,224.00
New appt from
COT first
124 33,852.00
236,340.00
Saving on COT
to October:
£47,924.44
Western Eye Hospital Wet-AMD Online/Fax Hybrid Direct Optometrist Fast Track Referral Pathway
Enhanced Service Description
Service Aims
Cost benefits
Wet Age-Related Macular Degeneration (wet-AMD)
accounts for more than 50% of blindness registration
in patients over 50 in England and Wales. Our direct
optometrist referral pathway empowers any high street
optometrist to refer patients directly for urgent wet
AMD assessment and routine retina specialist opinion
to our Macula Service at the Western Eye Hospital
through internet or fax. All cases conforming to the
NICE guidelines for wet AMD treatment are assessed
within 1 week and treated promptly within 7 days of
diagnosis as recommended by the Royal College of
Ophthalmologists.
1. To eliminate blindness
caused by wet AMD
delayed referral
For the last 11 months, we have
received a total of 129 direct referrals
from optometrists through our online/fax
referral system.
We have just now been given the green light to
proceed with one-stop Wet-AMD service. By the
middle of 2011, we will be able to set new standards in
AMD care by providing urgent wet AMD assessment
and treatment within 7 days from high street
optometrist referral.
2. To reduce NHS cost by
eliminating the need to
refer patients through eye
casualty or general
ophthalmology clinics.
3. To assess and treat
patients with wet-AMD
promptly resulting in early
stabilization of disease
and reduced number of
costly anti-VEGF eye
injections (£10,000
savings per patient).
This represents a saving for PCTs of
about £15,500 by eliminating redundant
A&E and general ophthalmology
consultations (£120 per session).
We are expecting a 3-fold increase in
direct optometrist referrals within the
next 12 months, resulting in consultation
savings up to £46,500.
In addition, we are working closely with
all major optical chains to eliminate
delayed wet AMD referrals (20 patients
per year). This will bring about
4. To promote better
enormous savings in treatment cost of
continuity of care between £10,000 x 20 patients = £200,000.
For further information on our referral system see:
community and acute
http://www.imperial.nhs.uk/gps/referralletters/index.htm
Minimum Annual Cost Savings for
healthcare provider.
West London = £46,500 + £200,000 =
Project Lead: Richard Cheong-Leen
£246,500
Nottingham University Hospitals
Enhanced Service Description
Greater demands are constantly being made on
limited NHS resources. These pressures impact
on the services we deliver, including the ability to
review patients in a timely manner. To meet
these demands new approaches to care
pathways and clinical protocols were developed.
Our service is established now and, working in
designated alongside consultant clinics,
Orthoptists now are seeing:
 epiphora patients (0-24 months) - assessment
and management including listing and
consenting for syringing and probing
 lumps and bumps - assessment and
management including listing and consenting
 uveitis screening for paediatrics with juvenile
idiopathic arthritis
 referrals of patients with a hearing impairment
who follow a specific care pathway
 assessment and management including listing
and consenting of paediatric and adult
patients with horizontal constant squint.
Lead: Isabel Ash
Service Aims
1. To reduce waiting time for
first appointment patients
2. To ensure that patients are
reviewed appropriately
Cost benefits
The orthoptic designated clinics see 7
patients per clinic with 2 clinics per week; in
addition, orthoptists are responsible for:
 a triage service for all paediatric and
adult strabismus clinics, including chose
and book, to ensure patients attend the
appropriate clinic
 a strabismus/ocular motility clinic where
orthoptic management only is required
 management of post-operative
strabismus patients, PGD for atropine
occlusion, on the day atropine refraction
The post-operative clinic alone has been
calculated to save 23 ophthalmologist
clinics per year. Inclusion of the other
orthoptic-led session would increase this
number considerably.
Tower Hamlets
Enhanced Service Description
 Orthoptic Led reception age vision screening
(done with Band 4 school nursing staff trained
by an Orthoptist who use the Thompson
Vision Screener) - almost 100% coverage last
year using opt-out consent.
 Orthoptic and Optometry Delivered Vision
Screening in the Borough 3 Special Education
Schools (one school for primary aged children
with profound disabilities, one school for
secondary aged children with profound
disabilities, and one school for children with
autistic spectrum disorders) - all children with
whom consent was gained were screened.
 Orthoptic and Optometry Delivered Vision
screening of children attending the Child
Development Team (CDT).
 Enhanced referral pathways direct from
Screening into the Hospital Eye Service.
* Contract covers Orthoptists and Optometrist
activity for all screening activities
Lead: Joe McQuillan
Service Aims
(1) To identify reduced visual
and potential sight
threatening vision problems
as early as possible in
mainstream and special
education schools to enable
early treatment and ensure
learning is not affected
(2) To provide yearly eye tests
for children in special
education schools
(3) To ensure young adults
leaving special schools
have an up to date eye test
and are given advice/
referral to the appropriate
service as part of the “Eye
Tests for Adults with
Learning Disabilities
Scheme”
Cost benefits
Cost analysis:
Contract for Orthoptic-Led Vision screening
in Mainstream Schools and
Orthoptic/Optometry Delivered Screening in
Special Education Schools and CDT
£33,500
Nursery Nurse Time (3272 children in
mainstream government and religious
schools in Tower Hamlets, almost 100%
coverage, screening takes between 5 and 8
minutes to screen each child - assuming
each child takes 8 minutes the cost is £2
per patient.
Maximum nursery nurse cost
£6544
Total cost £40,144.
Cost Saving = £32,016 per annum
With these advantages:
 Access to school lists to ensure
maximal uptake
 Clinical governance and audit
 Other tests such as height and weight
occur at the same time meaning
minimal disruption
 Parents informed of outcomes
Bexley Care Trust Repeat Measurement Scheme
Enhanced Service Description
Service Aims
The Bexley glaucoma repeat
1. To provide a service that fits
measurement scheme was
with the Quality, Innovation,
introduced in 2005 and used the
Productivity and Prevention
West Kent protocol as its basis. It
(QIPP) agenda.
provides a service where community
2. To reduce unnecessary
optometrists can improve the quality
referrals to the hospital eye
of referrals by repeating IOP
service, thereby releasing
measurements using Goldmann or
secondary care capacity.
Perkins applanation tonometry
3. To provide earlier
and/or by repeating suspect visual
interventions and manage
fields. The protocol was updated
patients closer to home.
following NICE guidance to allow
4. To reduce patient costs and
applanation tonometry immediately
worry linked to hospital
after a sight test and again on
referrals
another occasion if necessary.
5. To provide more efficient,
cost effective services as
outlined in the Health White
Paper.
Clinical Lead:
David Parkins
Cost Benefits
The Bexley repeat measurement scheme resulted in
76% of patients not being referred (audit data
2007/08). In 44.5% of patients, where raised IOP was
found by non-contact tonometry, repeated
measurement by Goldmann / Perkins applanation
tonometry resulted referral being avoided.
Comparison has been made between the repeat
measurement service and referral refinement by
another practitioner in the Bexley community eyecare
team. Financial review demonstrated that repeating
measurements achieved 62% savings when
compared with secondary care tariff while refinement
resulted in a saving of only3.5%.
(Parkins DJ & Edgar DF. Comparison of the effectiveness of two enhanced
glaucoma referral schemes. Ophthalmic Physiol Opt 2011, 31, 343–352.)
If 400 patients use the scheme per year (using 07/08
full year data):
Total IOP repeat measurement costs = £21k
(£8k optometrist fees + £13k secondary care)
Total secondary care costs = £55k
(if all patients were referred)
Annual Cost Savings = £34k (population 200,000)