Download complete patient record card – send back to gp

SCHEDULE 1
DEFINITION AND INTERPRETATIONS
Agreement
this NHS contract together with its schedules
DPA
means the Data Protection Act 1998
FOIA
means the Freedom of Information Act 2000
Location/environment
the rooms, clinics or other physical location, space, area or accommodation
in which services are provided
Services
the services as set out in schedule 1, service specifications are provided by
the Provider pursuant to and in accordance with this Agreement
Patient
a person who receives treatment, care or services from the Provider as part
of provision of these services
Serious Untoward Incident
Any event, incident or circumstance that could or did lead to unintended or
unexpected injury (physical or psychological), disease, suffering, disability,
death, loss or damage to a patient or Provider or subcontracted staff
member
The Commissioner
NHS LAMBETH
The Provider
[xxx]
1
SCHEDULE 2
SERVICE SPECIFICATION – MINOR EYE CONDITIONS SERVICE (MECS) PILOT
1 SERVICE OUTLINE
1.1 The service provides for the assessment and treatment of a number of eye care conditions in the
community.
1.2 The service is provided by accredited local ophthalmic practitioners, who may be either
optometrists or ophthalmic medical practitioners (OMP), (for the purpose of this document the term
optometrist will be deemed to include OMPs) and who have a range of equipment to facilitate
detailed examination of the eye, as well as the specialist knowledge and skill.
1.3 The service is accessed by patients direct from the local optometrist, either by:
• self-referral to the service via local signposting ("self-referral")
• attending a GP or Pharmacist who recommends attendance and treatment ("GP or Pharmacist
referral")
• an optometrist may refer a patient to themselves for a MECS assessment if the patient and their
condition fulfil the MECS requirements, the practitioner would otherwise have referred the patient,
and s/he believes that undertaking a MECS assessment may avoid the necessity for referral
• attending another optometrist who does not provide the service
1.4 The service is available to all persons registered with a GP practice located within the
geographical area of Lambeth PCT/Clinical Commissioning Group (CCG) or Lewisham PCT/CCG (For
the purposes of this document PCT will be superseded by the CCG from April 2013).
2 SERVICE AIMS
2.1 The service aims to improve eye health and reduce inequalities by providing increased access to
eye care in the community.
2.2 The service utilises the knowledge and skills of primary care optometrists to triage, manage and
prioritise patients presenting with an eye condition.
2.3 Access to eye care for the conditions described in paragraph 4.1 will enable more patients to
receive treatment closer to their homes.
2.4 The service is expected to reduce the number of unnecessary referrals from primary care to
secondary care, supported by the provision of more accurate referral information if a referral is
made.
2.5 Relationships between optometrists, GPs, Pharmacists and the PCT and CCG will be further
developed.
2.6 The service will be run as a 2 year pilot.
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3 SERVICE PROVISION
3.1 The service shall be provided during the hours detailed in Part 3 of Schedule 1.
3.2 Referrals to the service shall be made in accordance with paragraph 4.9.
3.3 An optometrist or other person employed or engaged by the Contractor in respect of the
provision of the services under the Contract ("other responsible person") may refuse to provide the
service if an optometrist is unavailable to provide the service within the timescale provided for in
paragraph 3.4, but all reasonable endeavours should be made to ensure availability.
3.4 On receipt of a referral (including a self-referral), the optometrist or other responsible person
shall arrange for the assessment and, where appropriate, the treatment of the patient, within forty
eight (48) working hours of such referral.
4 SERVICE SPECIFICATION AND CRITERIA
4.1 Symptoms at Presentation Included in the Service
This service provides for the assessment and management of patients presenting with any of the
following:
• Loss of vision including transient loss – consider differential diagnosis (TIA, Temporal Arteritis)
• Ocular pain
• Systemic disease affecting the eye
• Differential diagnosis of the red eye
• Foreign body and emergency contact lens removal (not by the fitting practitioner)
• Dry eye
• Epiphora (watery eye)
• Trichiasis (in growing eyelashes)
• Differential diagnosis of lumps and bumps in the vicinity of the eye
• Recent onset of Diplopia – Consider Stroke (binocular diplopia always significant)
• Flashes/floaters
• Retinal lesions
• Field defects
• GP/Pharmacist referral if for an appropriate condition as indicated above.
4.2 Conditions likely to require onward referral
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4.2.1 The following conditions require the patient to attend an ophthalmic hospital (which includes
an ophthalmic department of a hospital) casualty or accident and emergency department ("hospital
eye services"):
• Severe ocular pain requiring immediate attention
 Severe infection
• Suspect Retinal detachment
• Retinal artery occlusion
• Chemical injuries
• Penetrating trauma
• Orbital cellulitis
• Temporal arteritis
• Ischaemic optic neuropathy
 Binocular Double Vision
4.2.2 The treatment of long term chronic conditions is not included within the service. Conditions
excluded from the service include :
• Diabetic retinopathy
• Long standing adult squints
• Long standing diplopia
4.2.3 An NHS sight test shall not be performed concurrently with assessment or treatment for this
acute service. Please note that the optometrist will need to prioritise the urgency of the conditions
presented. For example Flashes and Floaters will need to be seen within 1 working day of the
practice. If the Optometrist is not able to be seen within this timeframe, then they should seek to
refer on to another MECS optometrist or to Eye Casualty.
4.3 Procedures
4.3.1 Such procedures shall be undertaken as deemed clinically necessary by the relevant
optometrist after assessment of the patient’s History and Symptoms
4.3.2 All tests undertaken and results obtained must be recorded on the Optometric Patient Record,
even if the results are normal.
4.3.3 Any drugs or staining agents used during the examination or prescribed must be recorded on
the Optometric Patient Record.
4.3.4 All advice given to the patient (verbal or written) must be recorded on the Optometric Patient
Record.
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4.3.5 All detailed retinal examinations shall be undertaken under mydriasis using either 0.5% or 1.0%
Tropicamide from a single dose unpreserved unit (Minim) unless this is contraindicated. The reason
for not dilating must be recorded on the Optometric Patient Record.
4.3.6 The level of examination should be appropriate to the reason for referral. All procedures are at
the discretion of the optometrist; however the following guidelines should be adhered to:
• Fundus examination should be through a dilated pupil when required or appropriate.
• Examination of an uncomfortable red eye must involve a slit-lamp examination used in conjunction
with a staining agent.
• Visual field examination results must be in the form of a printed field plot rather than a written
description.
• Symptoms of a sudden reduction in vision should be investigated by the examination of the macula
and retina using a Volk or similar lens.
• Symptoms of sudden onset flashes and floaters should be investigated by an examination of the
anterior vitreous and peripheral fundus with a Volk or similar lens and relative afferent pupil defect
(RAPD) testing is essential.
• Epilation of eyelash capability is essential.
4.4 Clinical Management Guidelines (see Appendix 3)
http://www.college-optometrists.org/en/professional-standards/clinical_management_guidelines/index.cfm
Clinical Management Guidelines for specific conditions should be adhered to unless this is
contraindicated. All clinical decisions and advice given to patients must be recorded on the
Optometric Patient Record.
4.5 Equipment
The Contractor shall have the following equipment:
• Slit lamp
• Contact and Non-Contact Tonometer
• Threshold field equipment to produce a printed field plot
• Ophthalmoscope
• Amsler charts
• Epilation equipment
• Diagnostic drugs (mydriatics, stains, local anaesthetics etc)
• Volk type lens
• Equipment to remove foreign bodies
4.6 Medication
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4.6.1 Optometrists may sell or supply all pharmacy medicines (P) or general sale list medicines (GSL)
in the course of their professional practice, including 0.5% Chloramphenicol antibiotic eye drops in a
10ml container.
4.6.2 Optometrists may give the patient a written (signed) order for the patient to obtain the above
from a registered pharmacist, as well as the following prescription only medicines (POMs):
• Chloramphenicol
• Cyclopentolate hydrochloride
• Fusidic Acid
• Tropicamide
4.6.3 In making the supply to the patient the ophthalmic practitioner must ensure:
• Sufficient medical history is obtained to ensure that the chosen therapy is not contra-indicated in
the patient
• All relevant aspects, in respect of labelling of medicine outlined in the Medicine Act 1968 are fully
complied with
• The patient has been fully advised on the method and frequency of administration of the product
4.6.4 In general, supply via a pharmacist is preferred. The College of Optometrists has produced
guidelines on the use & supply of drugs as part of its ‘Code of Ethics &Guidelines for Professional
Conduct’ section 2.40. If the patient is exempt from prescription charges, supply of appropriate
treatments could be covered by Group Prescribing Directives and/or by Minor Ailment Services in
accordance with The National Pharmacy Enhanced Service Plan already in existence.
4.7 Accreditation - Education & Training
4.7.1 The Contractor and all optometrists employed or engaged by the Contractor in respect of the
provision of the enhanced services shall satisfy the accreditation criteria detailed in this paragraph
4.7.
4.7.2 To become accredited, optometrists must be able to identify a range of ocular abnormalities
and must demonstrate proficiency in the use of the above mentioned equipment. Participating
optometrists must be registered with the General Optical Council.
4.7.3 Participating optometrists must complete the Cardiff University/LOCSU MECS Distance
Learning modules (Part 1) and the associated Practical Skills Demonstration (Part 2). Part 1 must be
completed before Part 2. An optometrist who has a relevant higher qualification and experience may
be exempt from the MECS Distance Learning and/or the Practical Skills Assessment at the discretion
of the Clinical Lead. A list of the competencies covered is found in Appendix 4
4.7.4 Optometrists will be required to attend a training session run by the LOC and PCT/CCG,
primarily to cover the administrative procedures and protocols involved in providing the enhanced
service. The training session will cover:
• An introduction to the service
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• Administration of the service including protocols, processes and paperwork
This training session may be held in conjunction with Ophthalmologist led lectures and the Part 2
assessment at the discretion of the PCT/CCG.
4.7.5 Optometrists will be required to attend at least 2 sessions in Eye Casualty or Rapid Access
Clinics during the first six months of their participation in this programme and then every six months
thereafter. In addition, ad-hoc training will be arranged by the Consultant appointees which
participating Optometrists will be expected to attend.
4.7.6 Should the service be commissioned after the pilot all participating optometrists will be
required to successfully complete a re-accreditation process every three (3) years.
4.7.7 Optometrists will be required to comply fully with the requests of both the PCT/CCG and the
Clinical Audit leads in making patient information and activity data available
4.7.8 The PCT/CCG will provide GPs and optometric practices with a regularly updated list of
contractors providing the service.
4.7.9 The Contractor shall be responsible for ensuring that all persons employed or engaged by the
Contractor in respect of the provision of the services under the Contract are aware of the
administrative requirements of the service.
4.8 Patient Eligibility
4.8.1 The service is available to all persons resident within the geographical area of
Lambeth,Southwark and Lewisham PCTs (CCGs after March 2013). The PCT/CCG will endeavour to
gain reciprocal agreements with other neighboroughing boroughs, and progress will be reported to
participants in due course
4.8.2 The Contractor shall ensure that the patient is an eligible person by verifying the patient’s
address before providing the enhanced service.
4.8.3 The Contractor must bill each PCT/CCG separately in respect of the patients seen from that
borough. For example, if in a month a Contractor has seen 15 patients from Lambeth and 8 patients
from Lewisham, Lambeth PCT/CCG should be invoiced for 15 patients and Lewisham should be
invoiced for 8 patients. A full list of invoice codes/addresses is available from the SE London
Optometric Advisor.
4.9 Referral and Patient Pathway
4.9.1 Accredited optometrists will receive referrals from GPs/Pharmacists using a Patient
Information Leaflet which will be distributed by NHS Lambeth and NHS Lewisham.
4.9.2 If patients are referred into MECS via the accredited MECS optometrist, no referral form is
necessary.
4.9.3 Each patient requiring an assessment and/or treatment under the service will be provided with
an Information Leaflet describing the service and including a list of contractors (see 4.9.1).
4.9.4 Patients shall make a mutually convenient appointment with the Contractor, and shall be
encouraged to telephone the practice premises.
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4.9.5 If the Contractor is unable to provide for the assessment and where appropriate, the treatment
of the patient within the timescale described in paragraph 3.4, the Contractor, optometrist or other
responsible person shall direct the patient to an alternative provider of the services, by way of the
list of contractors supplied by the PCT/CCG.
4.9.6 If urgent onward referral to hospital eye services is required, in accordance with paragraph
4.2.1, the ophthalmic practitioner shall advise the relevant hospital eye service by telephone and a
copy of the Optometric Patient Record shall be given to the patient to present on attendance.
4.9.7 Where a sight test/routine eye examination is required, the Contractor, optometrist or other
responsible person shall direct the patient to their usual community optometrist. A copy of the
patient's Optometric Patient Record shall either be sent via a secure NHS net e-mail or faxed to
such community optometrist within twenty four hours or if there is no NHS net address or secure fax
at the receiving practice, given to the patient to present on attendance.
4.9.8 The Contractor, optometrist or other responsible person shall provide the patient with a paper
copy of their Optometric Patient Record Card, if requested.
4.9.9 The Contractor, optometrist or other responsible person shall send a copy of each patient's
Optometric Patient Record to the patient's GP, where a prescription is required, (unless they have
the relevant qualification and can issue an NHS prescription if appropriate) within twenty four
working hours.
4.9.10 The Contractor shall provide all appropriate clinical advice and guidance to the patient in
respect of the management of the presenting condition.
4.9.11 Where appropriate, the Contractor, optometrist or other responsible person shall provide the
patient with an Information Leaflet on his/her eye condition.
4.9.12 Should a patient fail to arrive for an appointment, the optometrist must contact the patient
within 24 working hours, informing them that they have missed their appointment, and ask them to
arrange a further appointment.
4.10 Follow-up Processes
4.10.1 Treatments shall not routinely attract a follow-up appointment. All follow-up appointments
must be clinically justified.
4.11 Record Keeping and Data Collection
4.11.1 The optometrist shall fully complete, in an accurate and legible manner, an Optometric
Patient Record in the format provided by the PCT /CCG for each patient managed.
4.11.2 The Optometric Patient Record will provide for:
• The urgent referral of patients by an ophthalmic practitioner to the hospital eye services
• The referral of patients to their GP for joint management
• The referral of patients to their usual community optometrist for a sight test/routine eye
examination
• The management of patients by the optometrist
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4.11.3 The Contractor, optometrist or other responsible person shall also maintain a summary of:
• The number of patients for whom an appointment was booked and the source of the referral (as
set out in paragraph 1.3)
• The number of appointments booked for patients who did not attend ("DNAs")
4.12 Performance Reporting and Audit Reporting Requirements and Timescales
4.12.1 A report on activity and patient outcomes shall be forwarded by the Contractor to the
PCT/CCG by the 25th day of the month following the month in which the patients received the
service.
4.12.2 Clinical Governance issues shall be reported by the Contractor to the PCT/CCG by exception,
in accordance with paragraph 5.2.
4.12.3 Complaints shall be reported quarterly by the Contractor to the PCT/CCG.
4.12.4 Other relevant information required from time to time by the PCT/CCG shall be provided by
the Contractor in a timely manner.
4.13 Service Review
4.13.1 The Contractor shall co-operate with the PCT/CCG as reasonably required in respect of the
monitoring and assessment of the services, including• Answering any questions reasonably put to the Contractor by the PCT/CCG
• Providing any information reasonably required by the PCT/CCG
• Attending any meeting or ensuring that an appropriate representative of the Contractor attends
any meeting (if held at a reasonably accessible place and at a reasonable hour, and due notice has
been given), if the Contractor’s presence at the meeting is reasonably required by the PCT/CCG.
5 CLINICAL GOVERNANCE
5.1 Quality in Optometry
The Contractor must complete Level One and Level Two of Quality in Optometry within six months
of the Enhanced Service commencement date and provide evidence of this to the commissioner if
requested to do so.
5.2 Significant Incident Reporting
5.2.1 A record of all significant incidents (SI), near misses and potential incidents must be
maintained. SI must be reported to the designated quality lead within 24 hours.
5.2.2 All complications resulting from a MECS examination or treatment must be recorded on the
patient record.
5.3 Infection Control
5.3.1 Premises must be kept clean; this includes all areas of public access.
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5.3.2 In all consulting and screening rooms used, hard surfaces should be regularly cleaned using
appropriate hard surface solution / wipes.
5.3.3 Hand washing facilities must be provided in, or near, to consulting / screening rooms.
5.3.4 Hot and cold water should be available, and liquid soap and paper towels provided.
5.3.5 All equipment that comes into contact with patients must be cleaned after each patient. This
may be by using antiseptic wipes (or similar) for head / chin rests or by using disposable chin rests.
5.3.6 Disposable heads should be used for Tonometer prisms.
5.3.7 Epilation equipment must be appropriately sterilised between patients in accordance with
Royal College of Optometry guidance.
5.4 Waste Management
5.4.1 In accordance with College of Optometrists guidelines used tissues and paper towel can be
disposed of in your normal ‘black bag’ waste.
5.4.2 Part-used (or out of date) minims need to be incinerated, and can be discarded in a medicine
disposal box.
5.4.3 Chloramphenicol is regarded as hazardous waste and requires specialist incineration.
5.5 Clinical Audit
5.5.1 The Contractor shall participate in any clinical audit activity as reasonably required by the
PCT/CCG, and maintain appropriate records to evidence and support such activity, including an
electronic spreadsheet showing patient outcomes.
5.6 Patient Experience
The Contractor will participate in a patient survey by engaging patients in the completion of a
patient questionnaire, if required by the PCT/CCG.
6 PAYMENT
6.1 Payment for the service is on a cost per case arrangement. The PCT/CCG shall pay the Contractor
£47 for each first patient appointment and £28 for each follow-up appointment. (For the avoidance
of doubt, though, no payment shall be made by the PCT/CCG in respect of DNAs.)
6.2 Payment will be made to the Contractor monthly based on activity reports submitted by the
Contractor to the PCT/CCG to be received by the 25th day of the month following the month in which
the patients received the service. As referenced in 4.8.3, the Contractor must ensure that each
PCT/CCG is invoiced separately in relation to patients from their borough.
7 PARTICIPATING ACCREDITED OPTOMETRISTS
The optometrists named below have successfully undertaken accreditation and will provide the
Minor Eye Conditions service for patients presenting at the practice premises.
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The optometrists named below declare that they have read and understood this service
specification.
Name…………………………………….Signature…………………………………………………………Dated…………….
Name…………………………………….Signature…………………………………………………………Dated…………….
Name…………………………………….Signature…………………………………………………………Dated…………….
Name…………………………………….Signature…………………………………………………………Dated…………….
Name…………………………………….Signature…………………………………………………………Dated…………….
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LIST OF APPENDICES
APPENDIX 1 Forms


1a Record Card
1b Referral Form
APPENDIX 2 Patient Pathways


2a Referral Guidance for GPs
2b Condition Specific Pathways
APPENDIX 3 Samples of Management Guidelines



3a Flashes and Floaters
3b Age Related Macular Degeneration
3c Migraine
APPENDIX 4 Competencies
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MECS PATIENT RECORD CARD
PATIENT DETAILS: Title…………Surrname…………………………………………………………….
First Name(s)………………………………………………………………DOB…………………………..….
Address………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………
.......................................................................................Postcode………………………………………..
Telephone(s): H…………………………………………….. M……………………………………………….
W……………………………………………………………… GP name……………………………………….
GP Address……………………………………………………………………………………………………….
……………………………………………………………………………………………………………………
Date of examination…………………………………….
1ST APPOINTMENT
FOLLOW UP
(Tick one)
MECS referral by GP
Self Referral
(Tick one)
Did Not Attend (DNA): Yes / No Patient Contacted: Yes / No Date:
Further appointment booked
Time:
Patient declined appointment
History and Symptoms to include reason for visit, ocular history, general health, medication and
family history
Reason for MECS (write R in box if right eye, L if left or BE for both)
Red eye
Flashes and/or floaters
Headache
Loss of Vision
Diplopia
Painful white eye
Trauma
Other
Vision:
R:
PH:
Prescription used
SPH
CYL
AXIS
L:
PH:
Date if known
PRISM
VA
PH
Binoc:
ADD
Nr. VA
R
L
Cover test
Dist………………..……………….Nr……….……………………………………………..
Motility………………………………………………..NPC......................................................................
Muscle balance………………………………………Colour Vision……………………………………….
Pupils
IOP
Equal
size?
Direct
Cons.
Near
RAPD
R
L
Comments
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Visual field
R
L
Time:
Instrument used
R 1st………………………………2nd……………………………
L 1st……………………………....2nd……………………………
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MECS PATIENT RECORD CARD
Instrument used: …………………………………………………………………….
NB Visual Field Plots must be included with report/referral
SLIT LAMP EXAMINATION
Left
Right
LIDS &
LASHES
CORNEA
LENS
AC
AC/A
(e.g. Van Herick’s)-
Dilation
Drops used…………………………….
Y/N
OPHTHALMOSCOPY
Direct
Indirect
Right
Left
MEDIA
DISC
C/D RATIO
VESSELS (A/V)
MACULA
PERIPHERY
Other Tests:
Diagnosis (incl. differential diagnosis)
Advice to patient
Treatment
No Treatment
Management
Discharge – No ocular pathology
Ocular Pathology Present but can be managed in practice*
Referred to HES – pathology* (complete referral form) Emergency / Urgent/ Routine
Referred to GP
Systemic problem/ Eye Drops Required
*Patients GP must be notified
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MECS REFERRAL
Optometrists Name:
Please mark one box below CLEARLY as appropriate:
ACTION REQUIRED BY GP
(see notes below)
Patient Details
DR/MR/MRS/MISS/MS
DOB:
REPORT ONLY TO GP
(no further action required)
REFERRED TO
SECONDARY CARE
(send to CST)
First name(s):
Surname:
Address:
Contact telephone number(s):
Mobile:
Home:
NHS no:
Date of examination:
GP Details:
Address:
1st Appointment 
Follow Up: 
MECS referral by GP/ Optometrist
Optometrist Details:
Practice address:
(tick one)

Self-referral

(tick one)
GOC No:…………
History and symptoms: to include reason for visit, ocular history, general health, medication and family
history
Reason for MECS (write R in box if right eye, L if Left or BE if both)
Red eye
Flashes and/or floaters
Headache
Loss of Vision
Diplopia
Painful white eye
Trauma
Other
Current Rx: (Date if known)
V
Sph
Cyl
RE
LE
Mydriasis:
YES  NO 
Visual field plot
attached:
RE  LE 
Axis
Prism
Base
Other advanced
examinations:
VA
IOP:
RE
LE
PH
Add
Contact

Non-contact 
Diagnosis & action:
Referral to secondary care: YES/NO
Urgent  Routine 
Reason for referral to secondary care or action required by GP (please give clear and concise
reasons):
Domiciliary visit required: YES/NO
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Near
VA
2a Referral Guidance for GPs
MECS – PATIENT PATHWAY
PATIENT PRESENTS TO GP OR NON-PARTICIPATING OPTOMETRIST WITH EYE COMPLAINT.
INITIAL ASSESSMENT MADE AND UNABLE TO RESOLVE ISSUE
MAJOR - URGENT
MAJOR - NON URGENT
MINOR – URGENT & NON URGENT
DIRECT TO MECS OPTOMETRIST
PROBLEM
UNRESOLVED
PROBLEM
RESOLVED
SEE FOR
FOLLOW-UP (s)
SEND TO EYE
CASUALTY
REFER TO HOSPITAL EYE
SERVICE
DISCHARGE TO
GP
2b Condition Specific Pathways
APPENDIX 2a – Referral Guidance for GP’s: Minor Eye Conditions Scheme (MECS)
These flow charts should guide all treatment under MECS but practitioners are expected to use their experience and up to date knowledge in place of
them where appropriate
REASON FOR REFERRAL
Sudden loss of vision
Injuries : chemical, penetrating or post-op infection
Lids, lashes, tears: Entropion, Ectropion, Ingrowing eyelash
Mild Blepharitis
Watery eyes
Dry eyes
Chalazion/cysts
Childhood squint and/or amblyopia
Adult orthoptic assessment, particularly for diplopia
Sudden onset diplopia
Red eyes: which cannot be managed by the GP
Acute Glaucoma
Chronic Glaucoma/OHT
Corneal Conditions: such as small corneal foreign bodies or superficial
abrasions
Lens: Cataract
Macular degeneration: Wet/Dry
Vascular Abnormality:
MECS
Refer to MECS
Refer to MECS
Refer to MECS
Refer to MECS
Refer to MECS
Childhood vision problems should be seen under
the GOS by optometrists in the first instance
SECONDARY CARE
Urgent referral
Urgent referral
If surgery needed, refer
If persistent or needs syringing
If surgery required, to secondary care
Definite squints refer direct
Refer to Orthoptist
Urgent referral
Refer to MECS for differential diagnosis if unsure
and for treatment as indicated
Acute painful – urgent referral
Refer to GOS/LSL Referral Refinement Scheme
Refer to MECS
Refer via optometrist Direct Referral Cataract
Pathway (not MECS)
If dry (longstanding) or unsure
Urgent referral if wet, recent onset
distortion
Exclude giant cell arteritis and
cardiovascular abnormalities. Urgent
referral to secondary care for acute
presentation.
APPENDIX 2b Condition Specific Pathways
LIDS LASHES AND TEARS PATHWAY
PATIENTS PRESENT VIA MECS TO OPTOMETRIST
OPTOMETRIST TAKES HISTORY OF CONDITION AND EXAMINES ANTERIOR EYE BY SLITLAMP
BIOMICROSCOPY USING VITAL STAINS WHERE INDICATED
DIAGNOSIS
INGROWING
EYE LASH
ENTROPION/
ECTROPIAN
BLEPHARITIS
MANAGE, ADVISE
AND EPILATION
(MAX 3 EPISODES)
MANAGE AND
ADVISE
LUBRICANTS
MANAGE AND ADVISE
ARTIFICIAL TEARS
ANTIMICROBIALS
COMPLETE PATIENT RECORD CARD – SEND BACK TO GP
FOLLOW UP NOT
EXPECTED, BUT IF
PATIENT RE-PRESENTS
AND CONDITION NOT
IMPROVED, REFER FOR
ROUTINE
OUTPATIENTS
FOLLOW UP BY
OPTOMETRIST MAY BE
APPROPRIATE
REFERRAL IF SURGERY
INDICATED,
SYMPTOMATIC OR
DISFIGURING
FOLLOW UP BY
OPTOMETRIST MAY BE
APPROPRIATE. IF NO
IMPROVEMENT AFTER
3/12 THEN REFER
EPIPHORA DUE TO
BLOCKED PUNCTUM
DRY EYES
CHALAZION
MANAGE AND
ADVISE, BUT REFER
TO SECONDARY
CARE IF SYRINGING
NEEDED
MANAGE - FIT
PUNCTUM PLUGS IF
WITHIN COMPETENCY
OR REFER TO ROUTINE
OUTPATIENTS
ARTIFICIAL TEARS
MANAGE OR
REFER TO
ROUTINE
OUTPATIENTS IF
SURGERY NEEDED
ANTIMICROBIALS
COMPLETE PATIENT RECORD CARD – SEND BACK TO GP AND
HOSPITAL (WHERE APPROPRIATE)
FOLLOW UP BY
OPTOMETRIST
NOT EXPECTED
COMPLETE PATIENT RECORD CARD – SEND BACK TO GP AND
HOSPITAL (WHERE APPROPRIATE)
18
FOLLOW UP BY
OPTOMETRIST
NOT EXPECTED
APPENDIX 2b Condition Specific Pathways
CORNEAL PATHWAY
PATIENTS PRESENT VIA MECS TO OPTOMETRIST
OPTOMETRIST TAKES HISTORY OF CONDITION AND EXAMINES ANTERIOR BY SLITLAMP
BIOMICROSCOPY USING VITAL STAINS WHERE INDICATED
DIAGNOSIS
SMALL CORNEAL
FOREIGN BODIES
SUPERFICIAL
CORNEAL
ABRASIONS
RECURRENT
EPITHELIAL
EROSION
PTERYGIUM OR
PINGUECULAE
KERATITIS
CORNEAL
ULCER
HERPES SIMPLAR /
ZOSTER
MYDRIATIC FOR PAIN
REMOVE FOREIGN
BODY AND
MANAGE
ANTIMICROBIALS
MANAGE AND
PRESCRIBE USING
PGD
ANTIMICROBIALS
MANAGE AND
ADVISE
LUBRICANT &
ARTIFICIAL TEARS
MANAGE AND
ADVISE BUT REFER
IF SURGERY REQD
ARTIFICIAL TEARS
MANAGE IF ABLE.
IF ANY INFILTRATES
OR PATIENT IN
PAIN, SEND TO EYE
CASUALTY / RAPID
EYE CLINIC
SEND TO EYE
CASUALTY / RAPID
EYE CLINIC
SEND TO EYE
CASUALTY/ RAPID
EYE CLINIC
COMPLETE PATIENT RECORD CARD – SEND BACK TO GP
APPENDIX 2a Referral Guidance for GPs
COMPLETE PATIENT
RECORD CARD – SEND
BACK TO GP AND
HOSPITAL (WHERE
APPROPRIATE)
FOLLOW UP MAY BE APPROPRIATE
FOLLOW UP IN
SECONDARY CARE
19
COMPLETE PATIENT RECORD CARD – SEND BACK TO GP AND HOSPITAL
(WHERE APPROPRIATE)
FOLLOW UP MAY BE
APPROPRIATE BY
OPTOMETRIST OR IN
SECONDARY CARE
FOLLOW UP IN SECONDARY CARE
APPENDIX 2b Condition Specific Pathways
FLASHES AND FLOATERS PATHWAY
PATIENTS PRESENT VIA MECS TO OPTOMETRIST
OPTOMETRIST TAKES HISTORY OF CONDITION AND UNDERTAKES AN ANTERIOR VITREOUS
ASSESSMENT BY BINOCULAR INDIRECT OPHTHALMOSCOPY OR OTHER APPROPRIATE TECHNIQUE
DIAGNOSIS
FLASHES AND FLOATERS
ARE FLOATERS MINOR OR ACUTE ONSET
OF DOZENS OF FLOATERS OR CHANGED IN
NATURE?
VITREOUS
HAEMORRHAGE
MANAGE IF MINOR OR LONG
STANDING. PROVIDE INFO LEAFLET
TO PATIENT. MANAGE AND
ADVISE
IF SIGNIFICANT OR IF TOBACCO DUST IN
ANTERIOR VITREOUS OR SUSPECT
RETINAL BREAKS OR TEARS THEN SEND
TO RAPID EYE CLINIC / EYE CASUALTY
SEND TO RAPID EYE CLINIC /
EYE CASUALTY
COMPLETE PATIENT RECORD CARD
– SEND BACK TO GP
COMPLETE PATIENT RECORD CARD –
SEND BACK TO GP AND HOSPITAL
COMPLETE PATIENT RECORD CARD –
SEND BACK TO GP AND HOSPITAL
IF PATIENT RE-PRESENTS AND
CONDITION NOT IMPROVED REFER
TO HOSPITAL EYE SERVICE
FOLLOW UP WILL BE UNDERTAKEN IN
SECONDARY CARE
FOLLOW UP WILL BE UNDERTAKEN IN
SECONDARY CARE
COMPLETE PATIENT RECORD CARD –
SEND BACK TO GP AND HOSPITAL
20
APPENDIX 2b Condition Specific Pathways
OTHER OCULAR EMERGENCIES PATHWAY
PATIENTS PRESENT VIA MECS TO OPTOMETRIST
OPTOMETRIST TAKES HISTORY OF CONDITION AND UNDERTAKES AN APPROPRIATE ANTERIOR AND
POSTERIOR SEGMENT ASSESSMENT AND VISUAL FIELD EXAMINATION WHERE APPROPRIATE
DIAGNOSIS
CHEMICAL
INJURIES
PENETRATING
TRAUMAS
POST
OPERATIVE
INFECTION
ORBITAL
CELLULITES
ISCHAEMIC
OPTIC
NEUROPATHY
BLUNT
TRAUMA
ACUTE CLOSED ANGLE GLAUCOMA OR
OTHER CAUSE OF SEVERE PAIN
ESPECIALLY ASSOCIATED WITH VISION
LOSS
SEND TO EYE CASUALTY / RAPID EYE CLINIC
COMPLETE PATIENT RECORD CARD – SEND BACK TO GP AND HOSPITAL
FOLLOW UP WILL BE UNDERTAKEN IN SECONDARY CARE
21
APPENDIX 2b Condition Specific Pathways
RED EYE PATHWAY
PATIENTS PRESENT VIA MECS TO OPTOMETRIST
OPTOMETRIST TAKES HISTORY OF CONDITION AND EXAMINES ANTERIOR BY SLITLAMP
BIOMICROSCOPY AND POSTERIOR SEGMENT WHERE INDICATED
DIAGNOSIS
BACTERIAL
CONJUNCTIVITIS
MANAGE AND
TREAT UNDER
PGD IF
APPROPRIATE
ANTIMICROBIALS
ALLERGIC
CONJUNCTIVITIS
NON-HERPETIC
VIRAL
CONJUNCTIVITIS
SUB
CONJUNCTIVIAL
HEAMMORHAGE
IRITIS /
IRIDOCYCLITIS/
UVETITIS
SCLERITIS
EPISCLERITIS
MANAGE AND TREAT
UNDER PGD IF
APPROPRIATE
MANAGE AND
ADVISE
MANAGE AND
ADVISE
SEND TO EYE
CASUALTY /
RAPID EYE
CLINIC
SEND TO EYE
CASUALTY /
RAPID EYE
CLINIC
MANAGE AND
ADVISE
IBUPROFEN
MAST CELL STABILISERS
TOPICAL ANTIHISTAMINES
COMPLETE PATIENT RECORD CARD – SEND BACK TO GP
FOLLOW UP
NOT
EXPECTED
FOLLOW UP AFTER
3/12. NOTIFY GP TO
REPEAT TREATMENT
AS REQUIRED
FOLLOW UP
AFTER 6
WEEKS
COMPLETE PATIENT RECORD CARD
– SEND BACK TO GP AND HOSPITAL
COMPLETE
PATIENT RECORD
CARD – SEND BACK
TO GP
FOLLOW UP WILL BE UNDERTAKEN IN
SECONDARY CARE
FOLLOW UP NOT
EXPECTED. MAY
NEED REFERRAL
IF RECURRENT
FOLLOW UP
NOT EXPECTED
IF PATIENT RE-PRESENTS AND CONDITION NOT IMPROVED REFER TO HOSPITAL EYE SERVICE
22
APPENDIX 2b Condition Specific Pathways
VASCULAR ABNORMALITIES PATHWAY
PATIENTS PRESENT VIA MECS TO OPTOMETRIST
OPTOMETRIST TAKES HISTORY OF CONDITION AND EXAMINES ANTERIOR BY SLITLAMP
BIOMICROSCOPY USING VITAL STAINS WHERE INDICATED
DIAGNOSIS
HYPERTENSIVE
HAEMORRHAGE OR
FLAME SHAPED
HAEMORRHAGE
REFER TO GP
FOR CARDIOVASCULAR
WORKUP –
DO NOT REFER
TO SECONDARY
CARE
VENOUS
OCCLUSION
IF LONG
STANDING,
CHECK EYE
PRESSURE,
THEN REFER TO
GP FOR
CARDIOVASCULAR
WORKUP
COMPLETE PATIENT RECORD
CARD – SEND BACK TO GP
IF SUDDEN
ONSET, SEND
TO EYE
CASUALTY/
RAPID EYE
CLINIC
ARTERIAL
OCCLUSION
LESS THAN
24HRS,
SEND TO
EYE
CASUALTY/
RAPID EYE
CLINIC
COMPLETE PATIENT RECORD CARD
– SEND BACK TO GP AND HOSPITAL
AMAUROSIS FUGAX /
CHOLESTREROL EMBOI
FIELD LOSS –
HOMONYMOUS
HEMIANOPIA
REFER TO GP
FOR CARDIOVASCULAR
AND
NEUROLOGY
WORK UP.
DRIVING?
DVLA?
IF VISUAL
IMPAIRMENT
REGISTRATION
REQUIRED
REFER TO
ROUTINE
OUTPATIENTS
COMPLETE PATIENT RECORD CARD – SEND BACK TO GP
COMPLETE
PATIENT
RECORD CARD –
SEND BACK TO
GP AND
HOSPITAL
OVER
24HRS,
NONURGENT
REFERRAL
TO GP
REFER TO GP
FOR CARDIOVASCULAR
WORKUP
NO FOLLOW UP BY OPTOMETRIST EXPECTED
23
APPENDIX 2b Condition Specific Pathways
HEADACHE AND MIGRAINE PATHWAY
PATIENTS PRESENT VIA MECS TO OPTOMETRIST
OPTOMETRIST TAKES HISTORY OF CONDITION AND CONDUCTS APPROPRIATE EXAMINATION
DIAGNOSIS
HEADACHE
MIGRAINE
IF NO OPTOMETRIC EXPLANATION
REFER TO GP FOR NEUROLOGICAL
INVESTIGATION
ORTHOPTIC PROBLEM
MANAGE OR REFER TO ROUTINE
OUTPATIENTS
MANAGE AND ADVISE.
REFER BACK TO GP OR ORTHOPTIST
IF APPROPRIATE
COMPLETE PATIENT RECORD CARD
– SEND BACK TO GP
COMPLETE PATIENT RECORD CARD –
SEND BACK TO GP AND HOSPITAL
COMPLETE PATIENT RECORD CARD –
SEND BACK TO GP
FOLLOW UP BY OPTOMETRIST NOT EXPECTED
FOLLOW UP NOT EXPECTED
24
APPENDIX 3a
GUIDELINES FOR FLASHES & FLOATERS MANAGEMENT
Terminology
The following terms are important in this text:
Retinal break - This is a retinal hole or tear
Retinal detachment - This is any type of retinal detachment including rhegmatogenous, traction
or exudative
Optometric Assessment
History and Symptoms - A full and thorough history and symptoms is essential. In addition to the normal history
and symptoms, careful attention must also be given to the following:
History
• Age
• Myopia
• Family history of retinal break or detachment
• Previous ocular history of break or detachment
• Systemic disease
• History of recent ocular trauma, surgery or inflammation
Symptoms
• Loss or distortion of vision (a curtain / shadow / veil over vision)
• Floaters
• Flashes
For symptoms of floaters these additional questions should be asked:
• Are floaters of recent onset?
• What do they look like?
• How many are there?
• Which eye do you see them in?
• Any flashes present?
For symptoms of flashes these additional questions should be asked:
• Describe the flashes?
• How long do they last?
• When do you notice them?
For symptoms of a cloud, curtain or veil over the vision these additional questions should be asked:
•Where in the visual field is the disturbance?
•Is it static or mobile?
•Which eye?
•Does it appear to be getting worse?
Symptoms of less concern
•Long term stable flashes and floaters
•Symptoms >2 months
•Normal vision
Clinical Examination
All patients presenting for a MECS examination with symptoms indicative of a potential retinal detachment
should have the following investigations (in addition to such other examinations that the optometrist feels are
necessary):
•Tests of pupillary light reaction including swinging light test for Relative Afferent Pupil Defect (RAPD),prior to
pupil dilation
•Visual acuity recorded and compared to previous measures
•Contact tonometry, noting IOP discrepancy between eyes
•Visual Field examination at discretion of optometrist
•Slit lamp bio microscopy of the anterior and posterior segments, noting:
-
Pigment cells in anterior vitreous, 'tobacco dust' (Shafer’s sign)
-
Vitreous haemorrhage
-
Cells in anterior chamber (mild anterioruveitic response)
•Dilated pupil fundus examination with slit lamp binocular indirect ophthalmoscopy using a Volk or similar fundus
lens (wide field fundus lens optimal) asking the patient to look in the 8 cardinal directions of gaze and paying
particular attention to the superior temporal quadrant as about 60% of retinal breaks occur in that area. Noting:
-
Status of peripheral retina, including presence of retinal tears,holes, detachments or lattice degeneration
Presence of vitreous syneresis or Posterior Vitreous Detachment (PVD)
Management
If local protocols for the referral of retinal detachment are in place, then these should be followed. If not, you
should note that some HES ophthalmology departments will not have RD surgery facilities. In these cases it is best
to telephone the department first to find out what procedures to follow.
26
Symptoms requiring referral within 24 hours:
1. Sudden increase in number of floaters, patient may report as "numerous", "too many to count" or “sudden
shower or cloud of floaters” Suggests blood cells, pigment cells, or pigment granules (from the retinal pigment
epithelium) are present in the vitreous. Could be signs of retinal break or detachment present.
2. Cloud, curtain or veil over the vision. Suggests retinal detachment or vitreous haemorrhage – signs of retinal
break or detachment should be present
Signs requiring referral within 24 hours:
1. Retinal detachment with good vision unless there is imminent danger that the fovea is about to detach i.e.
detachment within 1 disc diameter of the fovea especially a superior bullous detachment, when urgent surgery is
required.
2. Vitreous or pre-retinal haemorrhage
3. Pigment 'tobacco dust' in anterior vitreous
4. Retinal tear/hole with symptoms
Signs requiring referral ASAP next available clinic appointment:
• Retinal detachment with poor vision (macula off) unless this is long standing Retinal hole/tear without
symptoms
• Lattice degeneration with symptoms of recent flashes and/or floaters
Require discharge with SOS advice (verbal advice and a leaflet)
1. Uncomplicated PVD without signs and symptoms listed above
2. Signs of lattice degeneration without symptoms listed above
Explain the diagnosis and educate the patient on the early warning signals of further retinal traction and possible
future retinal tear or detachment:
• Give the patient a Retinal Detachment warning leaflet
• Instruct the patient to return immediately or go to A&E if flashes or floaters worsen
Referral Letters
Patients requiring referral for retinal breaks or detachment must have the following noted on the referral form to
the ophthalmologist. Letters should be typed whenever possible and may be faxed or sent with the patient in
urgent cases.
• A clear indication of the reason for referral. e.g. Retinal tear in superior temporal periphery of Right eye
• A brief description of any relevant history and symptoms
• A description of the location of any retinal break / detachment / area of lattice
• In the case of retinal detachment whether the macula is on or off.
• The urgency of the referral
27
APPENDIX 3b
GUIDELINES FOR MANAGEMENT OF AGE-RELATED MACULAR DEGENERATION
Terminology
The following terms are important in this text & for differential diagnosis:
Wet (exudative) AMD - This can progress very rapidly causing loss of central vision & metamorphopsia
(distortion). It is characterised by sub retinal neovascular membrane, macular haemorrhages & exudates.
Dry (atrophic) AMD - A slowly progressive disease characterized by drusen & retinal pigment epithelial changes.
Optometric Assessment
History and Symptoms
A full and thorough history and symptoms is essential. In addition to the normal history and symptoms, careful
attention must also be given to the following:
History
• Age
• Family history of maculopathy
• Previous ocular history
• Systemic disease eg hypertension, diabetes
• History of ocular surgery- cataract extraction, retinal detachment repair
• Myopia
• Medication e.g. chloroquine derivatives, tamoxifen
• Smoking status
• Excessive exposure to sunlight/UV
Symptoms
• Loss of central vision
• Spontaneously reported distortion of vision
These additional questions should be asked:
• Is loss of vision of recent onset?
• In which eye are symptoms present?
• Has the loss of vision occurred suddenly or gradually?
Clinical Examination
All patients presenting for a MECS examination with symptoms indicative of a potential macular degeneration
should have the following investigations (in addition to such other examinations that the optometrist feels are
necessary):
28
• Tests of pupillary light reaction including swinging light test for Relative Afferent Pupil Defect (RAPD), prior to
pupil dilation
• Visual acuity recorded and compared to previous measures
• Refraction as a hyperopic shift can be indicative of macular oedema
• Amsler grid or similar assessment of central vision
• Dilated pupil fundus examination with slit lamp binocular indirect ophthalmoscopy using a Volk or similar
fundus lens noting:
-
Status of macula, including presence of drusen(&size), haemorrhages, pigment epithelial changes ie
hyper or hypo pigmentation, exudates, oedema, signs of sub retinal neovascular membrane
Management
If local protocols for the referral of AMD are in place, then these should be followed. If not, you should note that
some HES ophthalmology departments will not have the facilities to deal with wet age related macular
degeneration. In these cases it is best to telephone the department first to find out what procedures to follow.
Symptoms requiring referral ASAP next available clinic appointment:
1. Sudden deterioration in vision + VA better than 3/60 in affected eye
2. Spontaneously reported distortion in vision + VA better than 3/60
Signs requiring referral ASAP next available clinic appointment:
1. Sub retinal neovascular membrane
2. Macular haemorrhage
3. Macular oedema
Requiring routine referral:
1. Patient eligible & requesting certification of visual impairment
2. Patients requesting a home visit from Social Services to help them manage their visual impairment in their
home.
3. Patients who require an assessment for LVA
4. Patients likely to benefit from an intra-ocular Galilean telescope system
Low Vision Aids may be available in the community or hospital eye service - this varies in different areas.
Requires routine follow up but provide an Amsler chart, verbal advice and a leaflet (see sheet appended).
• Dry AMD, drusen &/or pigment epithelial changes
• Explain the diagnosis and educate the patient on the early warning signs of wet AMD.
• Give stop smoking advice via leaflet if appropriate + advice on healthy diet + protection from blue light
• Use 4 point scale to assess risk of AMD progression. Count one point for large drusen of 125 microns or larger
(about the size of a vein at the disc margin) and one point for any pigmentary change. Score each eye separately
29
and then add them together for a score out of 4. A full score of 4 points means a 50% chance of progressing to
advanced AMD in the next 5 years. 3 points gives a 25% chance, 2 points a 12% chance and with 1 point the risk is
just 3%.
• For those at intermediate risk of AMD progression give information on AREDS findings & leaflet on anti-oxidant
supplements
• Give information on local services for the visually impaired- public and third sector.
• Give appropriate information on national voluntary agencies e.g. RNIB, Macular Disease Society
• Instruct the patient to inform the practice or GP immediately if vision suddenly deteriorates or becomes
distorted.
Referral Letters
Patients requiring referral for macular degeneration must have the following noted on the referral form to the
ophthalmologist. Letters should be typed whenever possible and may be faxed or sent with the patient in urgent
cases. The Royal College of Ophthalmologists fast track referral form for AMD can be used
www.college-optometrists.org/en/utilities/document-summary.cfm/docid/81143450-07B2-4A16BA3ED6F3F7A86D77 (see appendix).
• A clear indication of the reason for referral. e.g. macular haemorrhage
• A brief description of any relevant history and symptoms
• A description of the type of macular degeneration or signs of drusen, pigment epithelial changes, sub retinal
neovascular membrane, haemorrhages, exudates, macular oedema.
• The urgency of the referral
Differential Diagnosis
Macular hole
This is a hole at the macula caused by tangential vitreo-retinal traction at the fovea. Causes impaired central
vision & typically affects elderly females
Macular epiretinal membrane
Can be divided into cellophane maculopathy & macular pucker
Central Serous Retinopathy
Typically sporadic, self-limited disease of young or middle-aged adult males. Unilateral localised detachment of
sensory retina at the macula causing unilateral blurred vision.
Cystoid Macular Oedema
An accumulation of fluid at the macula most commonly due to retinal vascular disease, intra-ocular inflammatory
disease or post cataract surgery.
Myopic Maculopathy
Chorio-retinal atrophy can occur with high myopia, usually > 6.00D, which can involve the macula.
Solar Maculopathy
30
Due to the effects of solar radiation from looking at the sun causing circumscribed retinal pigment epithelium
mottling or a lamellar hole at the macula.
Drug Induced Maculopathies
Antimalarials eg chloroquine, hydroxychloroquine
Phenothiazines eg thioridazine (melleril), chlorpromazine (Largactil)
Tamoxifen
APPENDIX 4
COMPETENCIES
1) The ability to take an accurate history from patients with a range of optometric conditions
2) The ability to elicit significant symptoms
3) The ability to elicit relevant family history
4) The ability to elicit issues pertaining to the patient's general health, medication, work, sports, lifestyle and
special needs
5) The ability to impart to patients an explanation of their physiological or pathological eye condition
6) An ability to understand a patient′s fears, anxieties and concerns about their visual welfare, the eye
examination and its outcome
7) The ability to discuss with a patient the importance of systemic disease and its ocular impact, its treatment and
the possible ocular side effects of medication
8) An ability to understand the patient′s expectations and aspirations and manage empathetically situations
where these cannot be met
9) The ability to communicate bad news to patients in an empathetic and understandable way
10) The ability to interpret and investigate the presenting symptoms of the patient
11) The ability to develop a management plan for the investigation of the patient
12) The ability to identify external pathology and offer appropriate advice to patients not needing referral
13) An understanding of risk factors for common ocular conditions
14) The ability to recognise common ocular abnormalities and to refer when appropriate
15) The ability to manage a patient presenting with a red eye
16) The ability to manage a patient presenting with reduced vision
17) The ability to manage a patient presenting with macular degeneration
18) The ability to evaluate and manage a patient presenting with symptoms suggestive of retinal detachment
19) The ability to examine fundi using direct and indirect techniques
31
32
SCHEDULE 3
ACTIVITY AND FINANCE
ACTIVITY
Activity levels will be closely monitored throughout the lifetime of the scheme, to ensure that they are helping to
deliver out of hospital treatment, whilst not generating such a level of demand that the scheme is unviable either
operationally or financially.
Therefore, based on 10 practices participating in the MECS scheme, each practice will be expected to see
approximately 274 patients per year and a further 118 for follow-up. These figures are based on the approved
business case for MECS which indicates that such levels are feasible.
Should a practice exceed, or be on track to exceed these levels of activity by 10% or more, the PCT/CCG reserve
the right to audit all referrals to check the validity of activity and the clinical appropriateness of the patient(S)
being seen through the MECS scheme.
FINANCE
Payment
Activity
£47 per first appointment
 First appointment seen by the Optometrist under
MECS and in accordance with Schedule 1. Any
follow up appointments for the same condition
must be recorded and charged as a follow up
appointment
£28 per follow-up appointment
 Collection of data as agreed in Schedule 2 and
Clause 8
 All invoices should be directed to the appropriate
PCT/CCG for that patient(s).
33
SCHEDULE 4
CLINICAL AND QUALITY STANDARDS
Requirements
Evidence
1. PATIENT SAFETY
1a. INCIDENT REPORTING
Clear systems are in place to ensure all
clinical untoward incidents / near misses are
reported, investigated, action plans in place,
implemented and monitored.
Policy in place
Incidents/significant event reports and reviews evidence of learning and change in practice
Practice / team meeting notes
1b. Serious untoward incidents
Reported to the PCT/CCG
2. INFECTION CONTROL
2a. Systems are in place to ensure
appropriate infection control procedures are
in place
Infection control policy in place inc. Sharps and
Waste management and Decontamination
Audit reports and action plans
3. RISK MANAGEMENT
3a. Systems are in place to ensure premises,
environment and equipment are fit for
purpose
Evidence of H&S checks
Risk assessments
Fire safety checks
Equipment maintenance checks
Procedure for reporting RIDDOR
34
Procedure for Safety Alert Bulletins
4. CLINICAL EFFECTIVENESS / AUDIT
4a. Systems are in place to deliver best
practice.
Protocols / guidelines / policies in place
4b. An annual audit programme is in place
Audit programmes for national / local priority practices,
report and action plans for improvement
5. EDUCATION / TRAINING
5a. Systems are in place to ensure staff
receive Continuous Professional
Development, relevant training
Training records for essential training
.




Fire
Basic Life Support
Equipment training records
Child and adult protection training
Annual Appraisal of staff
Personal Development plans
Supervision /mentoring arrangements
6. PATIENT / PUBLIC ENGAGEMENT
6a. Systems are in place to ensure all
complaints are investigated, appropriate
action taken and learning takes place
Policies / procedures
Compliments / Complaints
Action plans
6b. Systems are in place to ensure patient
opinion is sought used for improvement
Evidence of learning from incidents and or change in
practice
35
Patient input into planning services
Minimum annual Patient surveys and action plans
7. STAFF MANAGEMENT
7a. Systems are in place to ensure all the
necessary employment checks are
undertaken.
Procedure /Policies for checking:
CRB
Indemnity certificates
Professional Registration
Professional Qualifications
7b. Systems are in place to ensure job
descriptions and contracts are in place and
reviewed appropriately
Job descriptions
Contracts
36
SCHEDULE 5
VARIATION PROCEDURE
Part 1: Variation Procedure
1.
Any request for a Service Variation must be made in writing and shall give, unless otherwise agreed:
at least 3 months notice to the other where the request or proposal arises out of circumstances within the
control of the Party requesting or proposing the Service Variation; or
as much notice as possible where the circumstances leading to the request or proposal for a Service
Variation are outside the control of the Party requesting or proposing the Service Variation
2.
On receipt of a request for a Service Variation, the Provider and the Commissioners shall discuss the
proposal where appropriate and the receiving Party shall respond in writing as soon as is reasonably
practicable.
3.
The Parties shall use all reasonable endeavours to agree the Service Variation as soon as reasonably
practicably. If the variation is refused, the receiving Party shall give notice in writing to the other that the
Service Variation is refused, setting out reasonable grounds for such refusal.
4.
Agreement of any Service Variation must include agreement on the costs directly attributable to and
associated with implementing the proposed Service Variation and an appropriate amendment/addition to
this Agreement or its Schedules.
5.
Where the Provider requests or proposes a Service Variation, including for the avoidance of doubt
additional activity, new treatments, drugs or technologies, that would have a cost implication for any
Commissioner then:
the Provider shall provide to the Commissioners a full and detailed cost and benefit analysis of the
requested or proposed Service Variation;
the Commissioners shall, after consultation with the Provider, in its absolute discretion have the right to
decline the requested or proposed Service Variation; and
the Commissioners shall have no liability to the Provider whatsoever for the costs in any way arising
from the requested or proposed Service Variation should the Provider decide to implement the
requested or proposed Service Variation following the decision of the Commissioners to decline
the requested or proposed Service Variation under paragraph 5.2.
6.
Where the Provider requests or proposes a Service Variation that involves the withdrawal of a Service or
Services:
discussion of the variation shall commence as soon as possible;
if the requested or proposed Service Variation is agreed the Provider shall give all reasonable assistance
to the Commissioners in the planning, implementation and execution of any service exit plans
proposed by the Commissioners; and
where the Provider has given less than 3 months’ notice under paragraph 1 of the Service Variation, the
Provider shall be liable to the Commissioners unless otherwise agreed in writing, for all
reasonable losses and costs directly attributable to replacing the Service or Services being
withdrawn; and
7.
Any Service Variation made under this Schedule or the Agreement must be made having due regard to the
impact of the Service Variation on other Services.
8.
Following agreement of a Service Variation in accordance with the provisions of this Schedule 5 Part 1, the
Service Variation shall be given effect as a Variation to this Agreement in accordance with Clause 20
(Variations).
37
SCHEDULE 6
SERIOUS AND UNTOWARD INCIDENTS
All serious and untoward incidents must be reported within 72 hours of the information becoming known to the practitioner
on the DATIX Reporting System. This is in addition to a practitioner’s statutory obligations. Contact Marion Shipman
(Assistant Director of Governance), on 0203 049 4457 or email at [email protected] for any queries.
SCHEDULE 7
NHS COUNTER FRAUD AND SECURITY MANAGEMENT
NHS Counter-fraud and Security Management
Counter-Fraud and Security Management Provisions
1.1
The Provider shall:
(a)
from the date of this Agreement, put in place appropriate arrangements:
(b)
(i)
for the security of Staff providing NHS-funded care, for Patients receiving NHS-funded care and for
NHS resources and shall do so with reference to the NHS Security Management Service strategy
and the NHS Security Management Service national framework; and
(ii)
to prevent and detect fraud by the Staff, by or in relation to, Patients and/or in relation to public
funds with reference to the CFSMS strategy and the CFSMS national framework;
on request by the Commissioner permit any of:
(i)
the Local Counter Fraud Specialist nominated by each Commissioner from time to time;
(ii)
a person duly authorised to act on a Local Counter Fraud Specialist’s behalf;
(iii)
the Local Security Management Specialist nominated by each Commissioner from time to time;
(iv)
a person duly authorised to act on a Local Security Management Specialist’s behalf;
(v)
a person duly authorised to act on behalf of the NHS Counter Fraud And Security Management
Service;
to review the arrangements put in place by the Provider pursuant to paragraphs 1 (a)(i) and 1(a)(ii) of this
Schedule 13 and the Provider shall make such changes as a person described in paragraphs 1(b)(i) to
1(b)(v) of this Schedule 13 may reasonably require;
(c)
promptly, upon becoming aware of any suspected fraud or corruption involving Patients or public funds,
report such matter to the Local Counter Fraud Specialist of the relevant NHS Body; and
(d)
promptly upon becoming aware of any security incident or security breach involving Staff who deliver NHSfunded services or involving NHS resources, report such matters to the Local Security Management
Specialist of the relevant NHS Body (with a copy of such report being sent by the Provider to the Local
Security Management Specialist of the Commissioner).
Access
1.2
Upon the request of the Secretary of State for Health, or the Commissioner or the NHS Counter Fraud And
Security Management Service, the Provider shall ensure that the NHS Counter Fraud And Security
Management Service is given access as soon as is reasonably practicable, and in any event not later than
five (5) Operational Days from the date of the request, to:
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(a)
all property, premises, information (including records and data) owned or controlled by the Provider
relevant to the detection and investigation of cases of fraud and/or corruption; security incidents; and/or
security breaches directly or indirectly connected to this Agreement;
(b)
all members of the Staff who may have information to provide that is relevant to the detection and
investigation of cases of fraud and/or corruption; security incidents; and/or security breaches directly or
indirectly in connection with this Agreement.
SCHEDULE 8
SUB-CONTRACTORS
Part 1: Definition of “Material Sub-contract”
“Material Sub-contract” means any sub-contract entered into between the Provider and a Sub-contractor for the
provision of goods and/or services that are essential to the provision of any contracted activity, and that without
the sub-contracted goods and/or service the Provider would be unable to deliver the contracted activity or source
another sub-contractor within a timescale that would ensure no disruption to the contracted activity.
Part 2: Material Sub-contractors
Sub-Contractor
Description of Services/Goods Provided
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SCHEDULE 9
CONTACTS
Provider
Commissioner
[xxx]
NHS LAMBETH
1 Lower Marsh
T :[xxx]
Waterloo
E : [xxx]
London
SE1 7NT
xxx
T: xxx
E: xxx
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