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									5 Leeds PCTs
Leeds Teaching Hospitals NHS Trust

Contents                                                               Page No
1   Introduction                                                         1-4

    The Follow-up to New (FUN) ratio. What is it and how is it used?      1
    Definition of FUN ratio                                              1-2
    Utility features of FUN ratio                                        2-4
    Impact of the FUN ratio                                               4
    Aims of the project                                                   4

2 Methodology                                                            5-6

    Benchmarking Data                                                    5 -6
    Local Leeds case notes review                                         6

3 Findings                                                              7 - 16

    Benchmarking Data                                                   7 - 13
    Local Leeds case notes review                                       14 -16
    Summary of findings                                                   16

4 Observations                                                          17 - 22

    Mapping of the FUN ratio                                             17
    Benchmarking Data                                                    17
    Local Leeds case notes review                                      17 - 18
    Key influencing factors                                            18 – 19
    Recommended changes                                                  19
    Impact analysis                                                    19 - 22

5 Recommendations to optimise the FUN ratio                             23 - 25


National Questionnaire                                                  26 - 27

Abbreviations                                                             28

References                                                                29
5 Leeds PCTs
Leeds Teaching Hospitals NHS Trust

1        Introduction
The Follow-up to New (FUN) ratio. What is it and how is it used?

101      The term Follow-up to New (FUN) ratio (or its counterpart New to Follow-up ratio)
         has been used in discussions and data collection for both outpatient clinic
         attendances and elective day-case and in-patient episodes.

102      For example, much attention has recently been focused on the elective cataract
         patient pathway. The "Action on Cataracts" document, from the Department of
         Health Project Steering Group, proposed a significant improvement in access to
         cataract surgery, increased quality, reduced waiting times, and reduced variation in
         access across England. Variations in the patient journey through different
         ophthalmology units were highlighted in order to propose an optimised pathway that
         could meet these proposals. One such proposal involved combining the clinical and
         preoperative assessments, thereby halving the number of pre-operative patient
         visits. Changes needed to be made to allow for this, such as movement of
         equipment and health care personnel, changes to the clinic profile, and reduction of
         the waiting time from pre-assessment to surgery to avoid changes in most patients'
         health circumstances within this period.

103      This FUN ratio report studies patients' attendances to the ophthalmology outpatient
         clinic, although as will be demonstrated below, measurement method and impact
         need to be defined carefully.

Definition of FUN ratio

104      The first time a patient attends the ophthalmology unit for a clinic attendance is
         regarded as a new patient (NP) appointment. Subsequent visits for the same or
         other reasons are regarded as follow-up (FU) appointments. Local agreement is
         required to ascertain whether such appointments occurring in the hospital and
         community setting are regarded in a similar way.

105      For the purpose of this report, the FUN ratio is defined as:

              FUN ratio =               FU

106      Where FU = total number of follow-up patients (FU) seen and NP = total number of
         new patients (NP) seen.

107      This provides a whole number (as all patients attend clinic as NPs once before
         attending for a FU appointment), which in most cases can be expressed as a ratio to

108      For example, if 1,800 NPs and 5,400 FU patients are seen, the FUN ratio is
         5,400/1,800 = 3.

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109      When Trusts are asked for their figures of New and Follow-up attendances, this is
         usually expressed in total numbers, and the ratio may be expressed as a fraction or
         decimal of the New figure. So, for the example stated, if 1,800 NPs and 5,400 FU
         patients have attended, then the new to follow-up ratio would be expressed as
         1,800/5,400 = 0.33. For consistency, this report quotes all ratios as one or above,
         and are expressed as the FUN ratio.

Utility features of FUN ratio
110      It is unclear to what extent total numbers of new and follow-up attendances,
         expressed as a ratio, can impact on the day-to-day running of the Ophthalmology
         outpatient service. The following questions have been addressed in this report:

              What information is available at the present time?
              Can assumptions be drawn between FUN ratio and methods of practice/
               indicators such as diagnosis?
              How do Trusts differ in ratio and case mix, and how can we compare them?
              Can we learn from Trusts with a high or low ratio, when corrected for differences?
              What recommendations can we make regarding current and future practice?

111      There are a number of factors that influence the FUN ratio, namely:

              Factors affecting the total New Patient (NP) number
              Factors affecting the new patients requiring follow-up
              Factors affecting the follow-up number
              Non-clinical issues relating to data capture

Factors affecting the total New Patient (NP) number

              Referral patterns (primary care - GP, optometrist, primary care referral
              Population figures.
              Deprivation/local needs.
              Individual clinic profiles.
              Service provider capacity.
              Locally driven agreed activity.
              NHS targets for NP waiting time.

Factors affecting the NPs requiring FU

              Quality of initial referral.
              Organisation of accessory tests (eg fields, orthoptic assessment, photography,
               other investigations).
              Diagnostic case mix, individual clinician decision-making and clinic management.
              Co-management schemes.
              Patients that do not attend (DNA) appointments and the DNA policy at each

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Factors affecting the FU number

             Organisation of accessory tests (eg fields, orthoptic assessment, photography,
              other investigations as separate or combined appointments).
             Diagnostic case mix.
             Individual clinician decision-making and clinic management.
             Co-management schemes.
             Patients that do not attend (DNA) and the DNA policy at each Trust.

112      Here are two simple examples of where the FUN ratio differs in individual patient
         scenarios. Example Patient A describes a situation where the ratio may be different
         despite the same number of patient attendances and example Patient B describes a
         situation where the ratio differs with clinician management methods or patient

         Patient A

             Originally referred with a presumed diagnosis of glaucoma. First NP appointment
              confirms the diagnosis and a Glaucoma Management pathway is initiated. FU
              appointments are made at clinically appropriate time intervals. After 3 years, the
              patient develops a visually-significant cataract. They may then:

                         Enter a Cataract Care Pathway, with a NP episode followed by pre-
                          assessment, surgery and post-operative FUs. On completion of their post-
                          operative cataract care, they return to the Glaucoma Management


                         Continue review for both glaucoma and cataract care within the integrated
                          case notes.

Would patient care be better or worse depending which method were used? The FUN ratio
would be different in both cases.

         Patient B

             Originally referred with a disturbance at the macula. First NP appointment
              assesses the patient and further tests (photographs, fluorescein angiography) are
              arranged. At the next FU appointment, the test results are reviewed, a
              management plan approved and patient discussion ensues. Treatment is carried
              out and FU assessment of treatment success till a stable level is reached. Further
              deterioration in the clinical condition may occur, and the patient is made aware of
              the warning signs. The patient may then:

                           Be followed up at clinical appropriate intervals to assess stability, natural
                            history of the condition, and assessment of any further deterioration.
                            Increased number of FU appointments are likely to occur, thus
                            increasing the FUN ratio.

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                        Discharged with advice on how to access help should deterioration
                         occur. There are likely to be fewer FU appointments, and should the
                         patient notice a perceived deterioration, will be assessed as a NP. FUN
                         ratio is likely to be lower than the above option.

FU may be continued as per the doctor’s decision or if the patient expressed this as a

113      Many such scenarios are neither right nor wrong, but such differences in practice will
         undoubtedly make any proposals regarding present and ideal FUN ratios more
         difficult to interpret without further clarification.

Non-clinical issues relating to data capture

              Activity capture within the Trust – quality, consistency and reproducibility.
              Community activity, either by Trust staff or other providers.
              Diagnostic (Read) coding of diagnoses and coding of procedures.

Impact of the FUN ratio
114      Initial discussions regarding the ratio lead Health care teams to feel that a fuller
         understanding of the FUN ratio, areas where the ratio is particularly high or
         particularly low, may help us to shape an optimal service. However, great care must
         be taken with this implication. The above definitions and examples serve only to
         introduce the ambiguities and variations that occur with discussion of the ratio. This
         report aims to describe some of the information that is available, and suggest how it
         can be interpreted to demonstrate impact on clinical activity. Local discussion is
         required to be assured that information, interpretation and outcomes can be agreed.

Aims of the project
115      Agreed aims at the outset of this project were to:

                  Aim                                               Process

          Mapping of the       Map the range of FUN ratios at as many levels as appropriate/possible within
          FUN ratio            the available statistical information.

          Benchmarking Data    Obtain regional and national benchmarking information on ratios.

          Local Leeds case
                               Select three areas for study at the level of case review.
          notes review
          Key influencing
                               Identify key factors which influence the ratio.
          Recommended          Recommend changes to selected care pathways and/or discharge policy
          changes              which deliver the most appropriate ratio.

          Impact Analysis      Forecast the effect of the proposed changes on ratios and outpatient capacity.

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2        Methodology
Benchmarking data
201      An initial enquiry was made to find out if existing data on new and follow-up ratios is
         currently available. The Networking section describes what measures were used to
         collate existing information. The National Data section describes the enquiry made to
         explore the extent of information retrievable by units and to highlight differences
         between the information submitted.


202      Weekly Modernisation team meetings occurred in the attendance of Richard Tolson
         from the National Modernisation Agency. At a clinical networking meeting
         Jane Loughton from the Action On programme revealed that there is available data
         regarding outpatient attendances, DNA rates and FUN ratios1.

203      A local review of currently available data was undertaken as a starting point. This

             An individual consultant clinic profile over four weeks to determine case mix and
              FUN ratio. This provided information on the percentage of patients seen by
              medical diagnosis and highlighted the high percentage of patients with co-

             Leeds Teaching Hospitals Trust (LTHT) data capture on total outpatient
              attendances and FUN ratios for each consultant and clinic held within the Trust.
              This demonstrated clinics with insufficient clinicians where a high FUN ratio was
              noted and revealed available information on clinic profiles by sub-speciality.

             Other national benchmarking data available at LTHT that was used in consultant
              appraisal for peer comparison.

204      There are serious issues around data capture, both in quantity and
         quality/usefulness. The total number of outpatient attendances provided is likely to
         be a count of all patients who attended, not appointments given (to avoid inclusion of
         those who did not attend appointments and appointments that are rescheduled).
         Some clinics are designated as FU or NP attendances, and will be coded as such
         even though not necessarily accurate. Where a diagnostic code is used, there is
         variation in systems used and which is the preferred code if a patient has co-
         morbidity. Trusts will capture acute (A&E) attendances in different ways, which may
         be included in the outpatient attendance figures, or be monitored separately.
         Individual Trusts must be clear of their preferred method of data capture to make
         sure that any information they utilise is appropriate and representative.

205      This information was used as the basis to produce the National Survey
         questionnaire, and to compare and interpret FUN ratios. Further details are available
         upon request.

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National Dataset

206      99 Ophthalmology units across England were invited to complete a questionnaire
         (see Appendix) giving information on activity and FUN ratios.

207      This national dataset has been devised to gather three phases of information:

              Phase One : Demographics
               Contact details for each Trust, number of consultants, secondary catchment
               population served by the department, number of Primary Care Trusts (PCTs)
               served, teaching hospital status.

              Phase Two : Quantitative Information
               The information that is currently available regarding total NP and FU outpatient
               attendances, attendances by diagnoses and FUN ratio. Also a query regarding
               the data capture of acute ophthalmology cases.

              Phase Three : Qualitative responses
               This free text section begins with an enquiry to the unit whether outpatient access
               for FU patients is perceived as a problem. For Trusts who indicated that this was
               the case, further enquiry was made requesting what strategies the unit have been
               proposed or put into action to address these problems, what future strategies
               would be worthwhile and what barriers each unit perceived to implementing these
               strategies. Trusts were also asked to provide details of any protocols and
               guidelines currently in use.

Local Leeds case notes review
208      The purpose of the case notes review was to quantify the patient journey (visits
         required by the patient), in order to project FUN ratio modifications.

209      Traditional FUN ratios collect total numbers of NP and FU outpatient attendances.
         An alternative to collecting information in this way is to use the patient pathway to
         demonstrate the steps involved in a particular patient’s case. With this approach, it is
         possible to compare the pathway changes and the impact of such change.

210      A case notes pilot was performed in order to follow the visits an individual patient
         makes. A number of case notes of patients with a particular diagnosis (cataract,
         medical retina, paediatrics) were reviewed to plot the patient journey.

211      This formed the basis of discussion with healthcare professionals of the various
         steps currently involved and explore possible modifications.

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3                      Findings
Benchmarking Data

301                    Existing data on FUN ratios is available, collected by The West Midlands Strategic
                       Health Authority1. The graph below demonstrates the FUN ratio in descending order
                       within a number of hospitals within the Yorkshire region, and teaching hospitals
                       nationally for comparison with Leeds. Please note that this does not include
                       information from the National Survey and is therefore not anonymous.
                                     4              4
             4                                            3.8
                                                                                                      3.5       3.5          3.5
            3.5                                                                                                                               3.4

             3                                                                                                                                                2.9
FUN ratio

            2.5                                                                                                                                                                                   2.3










































National Dataset

302                    47 completed responses (48%) were received. Four units reported that they were
                       unable at the present time to provide the information requested. Reasons given were
                       insufficient data retrieval capabilities, change in the structure of the Ophthalmology
                       unit, and difficulties in ensuring accuracy of information where hospitals worked in a
                       hub-and-spoke arrangement.

303                    The majority of units provided data on total NP and FU patients, but two units
                       provided information labelled “all activity” which included procedure data eg surgery,
                       laser treatments etc. This skewed the data for these units toward higher follow-up

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304                        Secondary catchment population number was requested, but in some cases not
                           completed on the form. Ten units were able to provide data by diagnosis (eg
                           glaucoma, diabetes)

305                        The following information is currently available regarding phases one, two and three.

Phase One : Demographics

306                        From the National survey responses, there are no non-Teaching hospitals (blue
                           columns) with more than eight consultants, although the number of consultants per
                           hospital ranges from two to 44 consultants in Teaching hospitals (yellow columns).

307                        The graph below illustrates the number of consultants employed per hospital:


Number of hospitals




                           1     2     3     4     5     6          7            8       9        10         11    12       13      14       15
                                                                  Number of consultants

                                                             Teaching hospital       non-Teaching hospital

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308                                                                            The graph below illustrates the information gathered on numbers of consultants by
                                                                               local population for Teaching and Non-Teaching hospitals. It is expressed as the
                                                                               number of consultants per million of the population.
    number of consultants required for the catchement population stated



                                                                                                      13.7                                                                14.8



                                                                                                Teaching hospital                                                 non-Teaching hospital

                                                                                                       Royal College recommendation   National Survey   Leeds THT actual number

309                                                                            The first column represents the Royal College of Ophthalmologists recommended
                                                                               ratio of 1 consultant to 50,000 population for Teaching hospitals (ie 20 consultants
                                                                               per million population). The actual number is presented as a median, second column
                                                                               of 13.7 consultants per million patients (first quartile and third quartile 12.1 and 14.4
                                                                               respectively shown by the error bar), and the third column represents the actual
                                                                               number of consultants per million for the local Leeds population.

310                                                                            The fourth column illustrates the Royal College's recommended ratio of 1 consultant
                                                                               to 70,000 population for non-Teaching hospitals (ie 14.2 consultants per million), and
                                                                               the final column demonstrates the Survey's median ratio of 14.8 (first quartile and
                                                                               third quartile 11.4 and 15.5 respectively shown by error bar).

311                                                                            This is discussed further in the Observations section.

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Phase Two : Quantitative Information

312                   The graph below illustrates the range of FUN ratio arranged in descending order.
                      FUN rations were collected for two time intervals – April 2001 to March 2002 and
                      April 2002 to December 2002. The two FUN ratios were calculated, and the average
                      FUN ratio used in the graph.



  FUN ratio





                  1   2       3   4   5   6   7    8    9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41

313                   The median FUN value is 2.25, with a range of 1.2 to 5.5.

314                   Can further information help make comparisons of Trusts with different ratios? Can
                      we learn from units with a low FUN ratio and units with a high ratio?

Example of Low Ratio A

                                                            Teaching                                          No. of
                       Hospital                                            Number of
                                              Ratio         hospital                         Population        PCTs         Strategies in place
                         ID                                                consultants
                                                             status                                           served
                                                                                                                          Nurse led training,
                              117                 1.4                       8(6.2 WTE)         500,000            4       community optometry
                                                                                                                          clinics, staff grades
                              112                 1.35                           3.2              N/A             3       None
                                                                                                                          Nurse         glaucoma
                                                                                                                          clinics, direct access
                              132                 1.2       Teaching              4            500,000            4       cataract with optom
                                                                                                                          FU,      shared    care

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315      There is too much variance to draw meaningful conclusions, but it is interesting to
         note that two out of the three Trusts with low FUN ratios are non-Teaching hospitals,
         found earlier in the Findings to have a better proportion of consultant number per
         million population. All three Trusts commented that they had a problem obtaining
         clinic access for FU patients.

Example of High Ratio B

                                        Teaching                                  No. of
           Hospital                                 Number of
                         Ratio          hospital                   Population     PCTs     Strategies in place
             ID                                     consultants
                                         status                                   served

              104           5.8         Teaching         2         Nationwide       36     No

                                                                                           Nurse, optom,
               54           5.0         Teaching        11          760,000         5
                                                                                           Community Eye centre

               77           5.2         Teaching         4          280,000         2      Orthoptist

316      All three Trusts with the highest FUN ratio are Teaching hospitals. Here, the figures
         of population and PCTs served are unreliable due to tertiary referrals for sub-

Comparison of the benchmarking data

317      The two sources of data (the West Midlands Strategic Health Authority “Golden
         Bullets” data and the National Survey) were compared and found to be different. A
         data sample of five Yorkshire units and one teaching hospital were as follows:

                                                   West Midlands       National
                              Hospital ID
                                                       data            Survey

                                    54                  4.1              5.1

                                    35                  4                1.6

                                    47                  3.5              1.5

                                    52                  2.9              2.5

                                    49                  2.8              1.6

                                    86                  2.2              2.2

                             Median                     3.2              1.9

318      The median FUN ratio for these six units is 3.2 from the West Midlands data
         compared to 1.9 calculated from the National Survey. This highlights the variable
         nature of data and warns of inconsistencies with current methods of data collection.

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Phase 3: Qualitative responses

319                      Strategies each unit have proposed or put into action to address the problems with
                         increases in FU patients being seen are illustrated below:



 Number of Units






                        Glaucoma   Cataract MDT Diabetes MDT   NCCGs   Minor ops   FFA   bottox   MDT special Optom ref/CL   LVA   A+E N GP
                          MDT                                            N/GP                      (thyr vr)      com                PCC

320                      69 Multi Disciplinary Teams (MDTs) clinics have been instituted as strategies to deal
                         with the increasing number of patient with glaucoma, cataract and diabetic eye

321                      Barriers that units perceive to implementing these strategies

                                                                                                               Number of
                          Lack of cash                                                                            17
                          Lack of space                                                                               9
                          Lack of staff                                                                               6
                          Lack of vision                                                                              6
                          Lack of political recognition for FU                                                        2
                          Technology issues                                                                           2
                          Training issues                                                                             2
                          Staff retention                                                                             2
                          Specific pay scales/grading issues                                                          1
                          Lack of decision making                                                                     1
                          Bureaucracy                                                                                 1
                          Cumbersome documentation and protocols                                                      1
                          Prescribing issues                                                                          1
                          Change of practice                                                                          1
                          Project management requirements                                                             1
                          Medical input to develop/oversee                                                            1
                          Increase referrals from optoms and GPs                                                      1

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                                                                   Number of
          Diabetic screening                                           1
          Centrally driven NP pressure                                 1
          Cataract used as the only ideology                           1

322      Quality assurance- Guidelines available for use by Health Care professionals. The
         following Guidelines have been made available by the Units during the period of the
         Survey. Individual Units have local responsibility for them, and can be contacted
         directly if required.

                                        Protocol                    Hospital

          Protocol for nurse led pre-admission assessment           Blackpool
          Protocol for nurse led post operative review              Blackpool
          GP referral Guidelines                                     Bristol
          Glaucoma referral guidelines for GP and optometrists       Bristol
          Guidelines / Standards review                              Bristol
          Casualty protocol                                          Bristol
          Endophthalmitis protocol                                   Bristol
          Guidelines for Argon Laser trabeculoplasty                 Bristol
          Argon laser in diabetic retinopathy                        Bristol
          Indications for Fluorescein angiography                    Bristol
          Nurse-led pre-assessment clinics                           Bristol
          Criteria for Local Anaesthetic Day case surgery            Bristol
          Cataract Care pathway                                      Bristol
          Guidelines – Clinical Management                          Liverpool
          Guidelines – Primary Care                                 Liverpool
          Integrated Care Pathways – Strabismus surgery             Liverpool
          Integrated Care Pathways – Cataract surgery               Liverpool
          Integrated Care Pathways – Vitreo-retinal surgery         Liverpool
          Process Map – Cataract                                  Peterborough
          Process Map – Diabetic Retinopathy Screening            Peterborough
          Guidelines – Squint                                     Peterborough
          Guidelines – Visual impairment                          Peterborough
          Guidelines – Primary open angle glaucoma                Peterborough
          Guidelines – Red eye differential diagnoses             Peterborough
          Eye Department General Information pack                   Salisbury
          Guidelines for follow-up                                  Southend
          Integrated Care Pathways – Cataract surgery               St Helens

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Local Leeds case notes review
323      A sample of case records from seven clinics (1 dedicated cataract post-operative
         clinic, 2 cataract/general clinics, one general clinic, one medical retinal clinic and two
         paediatric clinics) were retrieved and monitored to measure FUN ratio for individual
         patients with a specific diagnosis. Please note that the FUN ratio here incorporates
         the number of patient-related episodes, and includes clinic attendances,
         surgery/laser attendances, and telephone reviews. The results are tabulated below:

          Clinic type:                             Cataract post-op clinic
          Number of patient journeys identified: 8
                              Number of
          Fu: NP Ratio                        Description
                  2:1             1           ?forgot to include tel. Review
                 3:1                6         Routine cataract
                4+:1                1         Complex cataract required ECCE

          Clinic type:                              Cataract/General
          Number of patient journeys identified: 15 (11 unfinished)
                              Number of
          FU: NP Ratio                        Description
                                              Glaucoma referral listed for trabeculectomy, anterior
                   1              2
                                              ischaemic optic neuropathy
                                              Glaucoma referral evolved to phacotrabeculectomy
                 1+:1             7           case, NP listed for surgery, cataract not visually
                                              significant at present time
                 2+:1             2           Cataract (pre-assessment expired), glaucoma
                 3:1                1         Cataract in a glaucoma case
                 9:1                1         Complex cataract (narrow angles)
                16+:1               1         Glaucoma
                39:1                1         Complex rubeosis, glaucoma and cataract

          Clinic type:                             General/Cataract
          Number of patient journeys identified: 3 (1 unfinished)
                              Number of
          FU: NP Ratio                        Description
                  1:1             1           Not suitable for surgery so LVA / BD8 arranged
                 8:1                1         Routine cataract and 2 x YAG capsulotomies
                24+:1               1         Complex cataract both eyes

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          Clinic type:                            General
          Number of patient journeys identified: 9 (3 unfinished)
                              Number of
          FU: NP Ratio                        Description
                  1:1             1           HZO walk-in Discharge
                  2:1                   1   ARMD, FFA then discharged
                 2+:1                   1   Glaucoma
                  3:1                   1   Cataract
                  4:1                   1   Cataract
                                            Complex cataract required ECCE, Cataract with post-
                 4+:1                   2
                                            operative uveitis
                 6+:1                   1   OAG and AMD
                 12:1                   1   Cataract both eyes

          Clinic type:                             Medical retina
          Number of patient journeys identified: 16 (7 unfinished)
                              Number of
          FU: NP Ratio                        Description
                                              Old patient referred as NP and discharged, dilated
                   1              2
                                              scleral vessels
                                              CSR with FU arranged, AMD, choroidal naevus, post-op
                 1+:1             4
                                              cataract with worsened diabetic retinopathy
                  2:1             1           CSR settled and discharged
                  3:1                   2   Retinal vein occlusion stabilised and discharged, AMD
                 3+:1                   1   AMD, BD8 and LVA
                 4+:1                   2   Retinal vein occlusion from A&E, choroidal naevus
                  5:1                   1   AMD, FFA, FU, LVA, BD8 and discharged
                                            AMD via A&E, referred consultant to consultant, FFA,
                  7:1                   1
                                            referred for surgical opinion
                                            A&E retinal vein occlusion, laser and FU, Choroidal
                 8+:1                   2
                                            naevus requiring FU

          Clinic type:                             Paediatrics
          Number of patient journeys identified: 5 (2 unfinished)
                              Number of
          FU: NP Ratio                        Description
                  1:1             1           Migraine
                 1+:1                   1   Neurosurgical referral, for CT
                  2:1                   1   Conjunctivitis
                 3+:1                   1   Orthoptist follow-up
                 16+:1                  1   Squint

Follow-up to New Ratio - October 2003                                                           Page 15 of 29
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          Clinic type:                            Paediatrics
          Number of patient journeys identified: 4 (unfinished)
                              Number of
          FU: NP Ratio                        Description
                   0              1           Urgent assessment arranged, patient DNA
                1+:1               1         Orthoptist FU to continue
                12+:1              1         Multiple DNAs
                                             Orthoptist and ophthalmologist FU combined where
                20+:1              1

         + indicates that the pathway is incomplete at the time of completion of the Case Notes review.

Summary of Findings
Dedicated cataract post-operative clinic

324      A streamlined approach to such patients demonstrated a FUN range of 2 to 4+. One
         patient was a complex case and required more FU appointments than the seven
         other patients.

Cataract/general clinic

325      A larger range of FUN ratios was found, and it appeared more difficult to restrict
         case mix in clinics where patients with cataract and patients with other ocular
         conditions were being assessed. Acute and subspecialty patients were seen
         amongst the cataract patients.

Medical retina clinic

326      A range of medical retina conditions and FUN ratios were demonstrated. Some of
         these were self-limiting, others gradually progressive such as Age-related Macular
         Degeneration (AMD) and vascular occlusions.

Paediatrics clinic

327      The pathways were so diverse, it is not possible to identify factors which can affect
         the ratio, other than caseload management and combining multidisciplinary visits (eg
         orthoptist, optometrist and ophthalmologist appointments).

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5 Leeds PCTs
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4        Observations
401      In this section, the original aims of the project have been revisited in order to
         interpret the findings and put them in context before making recommendations.

Mapping of the FUN ratio

402      Map the range of FUN ratios at as many levels as appropriate/possible within the
         available statistical information:

             Initial individual consultant clinic review of clinic attendances, measuring the
              proportion of diagnoses attending each clinic. Current data systems are not
              generally in place to capture all activity by diagnoses. This results in all clinic
              activity being recorded which may include minor surgical and laser procedures,
              photographs and specialised diagnostic assessments.

             LTHT consultant clinic FUN ratios. These ratios are quoted for each clinic held
              within the Trust, the values vary according to factors such as clinic specialisation
              (eg cornea, vitreo-retinal), number and grade of ophthalmologists per clinic and
              skill mix of health care professionals.

Benchmarking Data

403      Obtain regional and national benchmarking information on ratios:

             Existing Golden Bullets form the West Midlands Strategic Health Authority data
              and National survey undertaken.

             This information has given as an insight into the methods different units use to
              measure activity.

Local Leeds case notes review

404      This review served to follow an individual patient’s journey of new and follow-up
         attendances. Limitations of this type of review are that it is a small representative
         sample is retrospective and in many cases incomplete as the patient will require
         future clinic attendances at the time of the review.


405      Even clinics designated by presumed diagnosis eg cataract, cannot have only
         "straightforward" patients. Patients have co-morbidity eg glaucoma, unexpected
         vascular episodes, and capacity must allow for acute patients to be seen in a timely

Follow-up to New Ratio - October 2003                                                  Page 17 of 29
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406      Straightforward cataract patients can follow a streamlined pathway, and are thought
         to take up approximately 80% of the general cataract workload. Referrals may give a
         suggestion of whether a particular case is a straightforward one, but only on initial
         assessment can this be clarified. It may be possible to assign a grade to certain
         referrals and initial assessments, giving this information regarding anticipated clinical


407      Medical retina clinics contain patients with a variety of chronic eye disease
         conditions, one of which is AMD. One clinic demonstrates the requirement of tests
         (eg fluorescein angiography, low visual aids and assessment), procedures (eg partial
         sight certification, laser) and the subsequent FU with results.

408      Patients with a particular diagnosis eg choroidal naevus, may require long-term FU.
         There may be ways in which this FU can continue without such frequent clinic
         attendances, eg fundus photography. In this case, time and location would need to
         be allocated for the photography FU.

Paediatric ophthalmology

409      The review followed a particular patient through their NP and FU episodes. This
         helped to get a better understanding in depth of a small number of diagnoses or
         clinic specific issues. It also highlighted the wide range of cases.

Key influencing factors

410      The following are key factors which influence the FUN ratio:

               Dedicated cataract clinics instead of patients being seen amongst others with
                multiple pathologies.
               Combined initial assessment and pre-assessment investigations.
               Agreement of the optimal pathway for the majority of straightforward cases.
               Recognition of variance and allowing for flexibility within the pathway for this.


411      Patients should benefit from rapid management in the following way:

               Dedicated medical retina/AMD clinics.
               Minimised steps in the pathway
               Direct referral/fast tracking of more urgent cases
               Combined fluorescein angiography and assessment (MDT working) clinics
               On-hand low vision counselling, rehabilitation and low vision aids assessment

Page 18 of 29                                                         Follow-up to New Ratio - October 2003
5 Leeds PCTs
Leeds Teaching Hospitals NHS Trust

Paediatric ophthalmology

412      Paediatric ophthalmology clinics are usually considered as general clinics for
         children only, with certain special requirements (ie children friendly waiting facilities):

             MDT working (orthoptist, optometrist, ophthalmologist) has been standard for
              many years in this field.
             DNAs are a particular problem in paediatrics; combined clinics situated near the
              patient’s home and at suitable timing is preferable.

Recommended changes
413      Please see the Section 5, Recommendations.

Impact analysis


414      This example compares two different patient care pathways, based on an
         ophthalmology unit performing 3,000 cataract operations per year. Straightforward
         uncomplicated cases are assumed to occur in 80% of cases.

                                              Traditional    Optimised
                                               pathway        pathway
          New patient NP appointments            3,000          N/A
          Pre-assessment PA appointments         3,000          N/A
          Combined NP-PA appointments            N/A              3,000
          First eye operations                   3,000            3,000
          Day 1 postop visit                     3,000              600
          Day 1 telephone review                 N/A             [2,400]
          Week 1 postop FU                       3,000            3,000
          >1 week postop FU                      3,000              600
          TOTAL number of visits                18,000           10,200
          Net reduction in number of visits      N/A        7,800 = 43%

415      If the new pathway were streamlined:

             The NP and pre-assessment appointment occur together.
             The first day post-op FU is replaced in 80% cases by a telephone call. 20% of
              cases may be complicated surgery, cases with co-morbidity (corneal disease,
              diabetes, glaucoma) or social and geographic factors.
             The >1 week (routine) post-op FU is replaced by examination and refraction by
              the community optometrist.

416      The FUN ratio compares the traditional 6:1 with the optimised 2.4 (allowing for 20%
         patients requiring 1 day and >1 week FU. 7,800 visits could be utilised in a different
         way. The optimised FUN ratio increases to 4.8 with second eye surgery.

Follow-up to New Ratio - October 2003                                                   Page 19 of 29
5 Leeds PCTs
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417      However, there are some important assumptions:

               All NP visits are assumed to be of accurate quality such that further assessment
                (eg fields, intraocular pressure measurement) is not necessary, and that these
                patients are appropriately assessed as requiring timely surgery, and are available
                for visits and surgery when offered.

               Waiting lists are of appropriate length such that pre-assessment can occur at a
                correct time interval before surgery without lengthy delay.

               Surgery is performed on straight forward patients, who do not require day 1 post-
                operative assessment (eg known glaucoma, uncomplicated surgery, no corneal
                pathology). 80% of cases are deemed to be such straightforward patients, but
                units should audit their cases locally.

               Telephone assessment may be regarded as a part-visit, as it requires resource,
                with the availability for assessment if deemed necessary by health care
                professional or patient.

               Patients have no perceived or real problems after surgery requiring further
                assessment. In practice, follow-up is required for some patients several weeks
                after surgery.

               Decision regarding second eye surgery is taken either at pre-assessment for the
                first eye, or at the 1st/2nd week visit, to avoid extensive waiting between eye
                surgeries and a further pre-assessment.

Page 20 of 29                                                         Follow-up to New Ratio - October 2003
5 Leeds PCTs
Leeds Teaching Hospitals NHS Trust


418      This example compares two different patient care pathways, both occurring in the
         community and hospital for specialist services, commencing with the patient
         attending the optician (optometrist) with a problem thought to be related to AMD.
         FUN ratios can be reduced by combining visits, and a change in geographical
         distribution of the healthcare is perceived to be beneficial for patients

                                                        Patient attends Optometrist.
                                                        Patient attends Optometrist.

                                     Traditional pathway                                   Optimised pathway
                                                                                          Referral refinement OwSI,
                                                                                           GPwSI in comm/hospital
                                    Patient attends GP &
                                    Patient attends GP &                                 priority clinic. Assessment &
                                        referral sent.
                                         referral sent.                                 prioritisation with explanation.
                                                                                               Fast-track hospital
                                                                                            appointment assigned.

                                                                                                                     No further
                                                                                   Combined FFA,
                                                                                    Combined FFA,                     hospital
                                Referral priority assigned.                  assessment, explanation &
                                                                              assessment, explanation &             assessment
                                Referral priority assigned.
                                                                             laser treatment if required.
                                                                              laser treatment if required.            required

                                   1st clinic attendance                                LVA assessment, support,
                                    1st clinic attendance
                               assessment, explanation &                                rehab in combined visually
                                assessment, explanation &
                                clinic management plan.                                 impaired/sensory centre in
                                 clinic management plan.
                                                                                          hospital or community

                 FFA if required.
                 FFA if required.

                                                   Review appointment,
                                                   Review appointment,
           Laser treatment if required.
            Laser treatment if required.               explanation.

                                    LVA appointment.
                                     LVA appointment.

                                     Social services
                                     Social services
                                                                           Yellow background community based care
                                 rehab/support                             Blue background hospital based care
                                                                           White background community or hospital based care
Follow-up to New Ratio - October 2003                                                                             Page 21 of 29
5 Leeds PCTs
Leeds Teaching Hospitals NHS Trust

419      The number of steps in the pathway can be dramatically reduced leading to reduced
         patient waiting times.


420      There has traditionally been multi-disciplinary team working in the paediatric
         ophthalmology pathway, in both the community and hospital eye service. Referrals
         are made from health visitors, community paediatric service and education services
         in addition to general practice. Multiple attendances are sometimes required due to
         lack of co-operation with examination and assessment. Screening of siblings may be
         required. Social factors (eg school holidays, family illness, parental availability) often
         leads to an increased DNA rate. A wide variety of conditions are seen, some of
         which may required frequent attendances for monitoring.

Page 22 of 29                                                         Follow-up to New Ratio - October 2003
5 Leeds PCTs
Leeds Teaching Hospitals NHS Trust

5        Recommendations to optimise the FUN ratio
General principles regarding the Follow-up to New (FUN) ratio

501      The term optimisation of FUN ratios should be used rather than reducing the FUN
         ratio as the latter may promote less than optimal care. Optimisation of FUN ratios
         including enhanced clinical governance may lead to an increased ratio but this is
         likely to be far more complex for chronic care pathways where patients are currently
         unable to attend overcrowded outpatient facilities. Indeed, the method of measuring
         the FUN ratio by total number of attendances excludes those patients who should
         have been reviewed, but are still awaiting a clinic appointment, the “bow wave” 2.
         FUN ratio is determined by so many factors hat it should only be used where an
         optimal FUN ratio has been determined for a specific care pathway either locally or
         by a national process eg the National Eye Care plan. Only when the latter has been
         agreed should the FUN ratio become a target to be achieved.

Optimising the role of the hospital MDT

502      Apply the one-stop provision of several steps in the patient journey, which will
         reduce the number of FU appointments required for many patients. This is routine in
         glaucoma clinics where some patients undergo visual field testing and assessment
         at the same visit, but clinic profile and personnel modifications would allow more of
         such working. In particular eye health care staff may be multiskilled and devolved to
         areas where one-stop working can be achieved, eg biometry at cataract clinics (by
         nurses, optometrists or orthoptists), nurse-led fluorescein angiography at macular
         clinics. This is dependent on the number of such personnel being available and

Optimising the role of the community MDT

503      Increase the utilisation of primary care practitioners with an interest and appropriate
         experience in ophthalmology, eg optometrists, general practitioners and nurses. Use
         locally (or modified nationally) agreed protocols to aid clinical governance
         assessment. Paramount to this is a highly developed data collection system to
         ensure information sharing and audit tools. This is dependent on the number of such
         personnel being available and proficient.

Optimising the care pathway : Clinic decision making

504      Reduce redundant steps in the patient care pathway where possible, eg good quality
         referral will allow access to the appropriate clinical assessment, thereby reducing
         unnecessary delay and anxiety for the patient3&4 whilst additional tests are arranged.
         An evidenced based approach is required for local agreement to reduce steps such
         as first day post-operative telephone review for patients who undergo routine,
         uncomplicated cataract surgery.

505      Combine steps within the pathway such as cataract clinic assessment and pre-
         operative testing, glaucoma monitoring with fields and assessment.

Follow-up to New Ratio - October 2003                                                Page 23 of 29
5 Leeds PCTs
Leeds Teaching Hospitals NHS Trust

506      Implement an appropriate DNA policy5,6&7. Using the partial booking system, sending
         reminder letters or telephone calls nearer the appointment day will reduce non

507      Maximise clinical resources. Consider the role of each health care professional with
         emphasis on competence, skill mix, readiness to acceptance responsibility for
         decision making, willingness to train colleagues and opportunities to continue
         professional development.

508      Enhance the clinic role of specialist nurses, optometrists, orthoptists and GPs
         including assessment, diagnostic testing and carrying out a management plan for
         each patient. Where appropriate these specialists will embrace this opportunity to
         accept responsibility for decision making with support from the supervising
         consultant where necessary.

509      Effective utilisation of the consultant role8,9&10. Traditional the consultant assess
         patients in parallel with colleagues. There is an opportunity to assume a supervisory
         role for all patients passing through the clinic to optimise decision making, reduce
         follow-up attendances and generally oversee the running of the clinic, eg:

               the consultant reviews all case notes prior to clinic and suggests appropriate
                management11 (individual standardised protocol); or

               the health care professionals perform assessments and ultimate decision making
                lies with the consultant (individual standardised protocol); or

               the consultant sees all new patients (which tends to increase the first visit
                discharge rate); or

               the consultant sees all follow-up patients (which tends to decrease overall follow-
                up attendances).

Clinical governance issues

510      Optimise MDT working to a well-established supportive clinical governance
         framework, which allows flexibility for training, competence assessment, and
         continuing professional development. Tools for audit, risk management, and
         complaints procedures must be agreed at the outset, and evaluated at regular
         intervals. Continuing communication and health needs assessment will ensure that
         protocols and practice is appropriate, evidence-based and of the highest quality.

Data collection

511      Use accurate and comparative data systems12&13. Information technology support
         has already been shown to be highly variable between the units on the National
         Survey. The Department of Health “Golden Bullets” data provides different figures
         than those of the National survey. A state-of-the-art system is required that will allow
         electronic registration, recording and audit the whole pathway from initial referral to
         final visit.

Page 24 of 29                                                          Follow-up to New Ratio - October 2003
5 Leeds PCTs
Leeds Teaching Hospitals NHS Trust

Local Consultant per capita ratio

512      The Royal College of Ophthalmologists Guidelines for ratios of Consultant to
         population are 1 per 50,000 for Teaching hospital departments and 1 per 70,000 for
         non-Teaching hospital departments. The results from this study show that whilst the
         ratio for non-Teaching departments (1 per 67,640) appears to be adequate, the ratio
         for Teaching hospitals (1 per 72,848) falls well below the Royal College of
         Ophthalmologists Guidelines nationally.

513      LTHT Clinical Management Team for Ophthalmology currently serves a secondary
         catchment population of approximately 940,000 (760K Leeds + 180K North Kirklees
         PCT population). Thus the consultant per population ratio (1 per 80,617) is below the
         national average for Teaching hospitals (1 per 72,848) and well below Royal College
         Guidelines (1 per 50,000). To bring Leeds in line with the suboptimal national
         average would require the appointment of an additional 1.3 consultants, and to
         achieve Royal College recommendations would require an additional 7.2

Follow-up to New Ratio - October 2003                                              Page 25 of 29
5 Leeds PCTs
Leeds Teaching Hospitals NHS Trust

National Questionnaire                                                                                     1 of 2
 Trust Details
 Trust                                                         «Trust» NHS Trust

 Lead Clinician/Clinical Director                              «Con_Title» «Con_Initial» «Con_Surname»

 Manager                                                       «Mgr_Title» «Mgr_Initial» «Mgr_Surname»

 Number of Consultant Ophthalmologists in your Trust

 *Secondary Catchment population served by the
 Ophthalmology Department

 Number of PCTs served

 Are you a Teaching Hospital Trust?                                   Yes                          No

 Do you perceive a problem getting Ophthalmic clinic access
 for follow-up (review) patients?                                     Yes                          No

 Does your Trust have difficulties finding sufficient
                                                                      Yes                          No
 Ophthalmic follow-up (review) slots?

 Have you put into place any strategies to increase access to follow-up patients eg non-consultant, nurse-led or
 optometry (hospital or community) clinics? If so, please give details

 What strategies do you think would be worthwhile to address this issue?

 What do you feel are the main barriers to implementing these strategies?

Page 26 of 29                                                                Follow-up to New Ratio - October 2003
5 Leeds PCTs
Leeds Teaching Hospitals NHS Trust

National Questionnaire                                                                                    2 of 2

 For the catchment population identified overleaf please could you complete the table below with:

          numbers of new and follow-up patients seen for the year 1 April 2001 – 31 March 2002
          numbers of new and follow-up patients seen for the year 1 April 2002 – 31 Dec 2002 (first
           3 quarters)
          where possible, numbers by diagnostic code, eg glaucoma, diabetes, cataract etc:

 Please give details of the Read/OPCS codes you have used to collate these figures, eg:

                  68A2.      Glaucoma screen                 F45..   Glaucoma
                  F4504      Ocular Hypertension
                  F46..      Cataract                        7265y Capsular Opacity
                  F420.      Diabetic Retinopathy            3129.   Eye Fundus Photography

                                             01/04/01 - 31/03/02                   01/04/02-31/12/02
                                        First   Follow-up        Ratio       First   Follow-up     Ratio
 Total Ophthalmology                        new     review     review/new        new      review review/new
 Outpatient Appointments
 Glaucoma (all codes)
 Cataract (all codes)
 Diabetes (all codes)
 Hospital Paediatric
 Community paeds/orthoptist
 Casualty/Emergency referrals
 Outreach clinics

 What are your DNA rates for these time periods

 Acute ophthalmology details
 Are Casualty attendances at your Trust included in
                                                               Yes                      No
 your Total Ophthalmology Outpatient Appointments
 (quoted above)?

 How are your Eye casualty/acute referrals seen?

     Within the clinic

     Separate clinics held

     Casualties only seen on an on-call specialist
      referral service

 If you would like to discuss this further, please contact Andrew Cassels-Brown via email,
 on petra.strong@leedssouth-pct.nhs.uk

Follow-up to New Ratio - October 2003                                                               Page 27 of 29
5 Leeds PCTs
Leeds Teaching Hospitals NHS Trust

Abbreviation         Meaning

A&E                  Accident and Emergency
AMD                  Age-related Macular Degeneration
BD8                  partial sight certification to register patients with significant visual impairment
CSR                  Centroserous Retinopathy
CT                   Computerised Tomography scan test
DNA                  Did Not Attend
ECCE                 Extracapsular Cataract (large incision) cataract surgery
FFA                  Fundus Fluorescein Angiography test
FU                   Follow-up
FUN                  Follow-up to New
GP                   General Practitioner (family doctor)
HZO                  Herpes Zoster Ophthalmicus, shingles affecting the ocular tissues
LTHT                 Leeds Teaching Hospitals NHS Trust
LVA                  Low Visual Aids and assessment
MDT                  Multi Disciplinary Team
NP                   New Patient
OAG                  Open Angle Glaucoma
PCT                  Primary Care Trust

Page 28 of 29                                                                  Follow-up to New Ratio - October 2003
5 Leeds PCTs
Leeds Teaching Hospitals NHS Trust

1      “Golden Bullets Data” West Midlands South Strategic Health Authority in October
       2002. Contact: Andy Brown, Information department, telephone 01527 587574.

2      “The Bow Wave of Doom: A Preliminary Report of an Out-Patient Model”. Taylor RH.
       Eye News Vol 10:1 June/July 2003 pp18-27

3      Understanding patients' views of a surgical outpatient clinic. J Eval Clin Pract. 2000

4      Establishing patient preferences for gastroenterology clinic reorganization using
       conjoint analysis. Moayyedi P et al. Eur J Gastroenterol Hepatol. 2002 Apr;14(4):429-

5      Reducing non-attendance at outpatient clinics. Stone CA et al. J R Soc Med 1999 Mar

6      Shortening waiting lists in orthopaedic surgery outpatient clinics. West RR, McKibbin
       B. Br Med j (Clinc Res Ed). 1982 Mar 6;284(6317):728-30.

7      Trouble shooting section - Department of Health website. Plymouth Hospitals NHS
       Trust. July 2003.

8      Who undertakes the consultations in the outpatient department? Kiff RS, Sykes PA. Br
       Med J (Clin Res Ed). 1988 May 28;296(6635):1511-2.

9      Should consultant surgeons see new or follow-up patients? A prospecitve audit of a
       change in clinic organisation. Aitken RJ. Ann R Coll Surg Engl. 1996 Sep;78(5

10     Plastic surgery outpatient audit: principles and practice of "consultant only" clinics.
       Griffiths RW. Br Plast Surg. 1990 Nov;43(6):735-41.

11     Audit of a new appointments system in a hospital outpatient clinic. Jennings M. BMJ.
       1991 Mar 2;302(6775):532-3.

12     Improving outpatient clinic efficiency using computer simulation. Clague JE et al. Int J
       Health Care Qual Assur Inc Leadersh Health Serv. 1997:10(4-5):197-201.

13     Operations research survey and computer simulation of waiting times in two medical
       outpatient clinic structures. Edwards RH et al. Health Care Anal. 1994 May;2(2):164-

Follow-up to New Ratio - October 2003                                               Page 29 of 29

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