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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 Appendix 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 NP 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 one. 108 For example, if 1,800 NPs and 5,400 FU patients are seen, the FUN ratio is 5,400/1,800 = 3. Follow-up to New Ratio - October 2003 Page 1 of 29 5 Leeds PCTs Leeds Teaching Hospitals NHS Trust 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 refinement). 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 Trust. Page 2 of 29 Follow-up to New Ratio - October 2003 5 Leeds PCTs Leeds Teaching Hospitals NHS Trust 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 preferences: 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 pathway. Or 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. Follow-up to New Ratio - October 2003 Page 3 of 29 5 Leeds PCTs Leeds Teaching Hospitals NHS Trust Or 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 preference. 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. factors 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. Page 4 of 29 Follow-up to New Ratio - October 2003 5 Leeds PCTs Leeds Teaching Hospitals NHS Trust 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. Networking 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 included: 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- morbidity. 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. Follow-up to New Ratio - October 2003 Page 5 of 29 5 Leeds PCTs Leeds Teaching Hospitals NHS Trust 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. Page 6 of 29 Follow-up to New Ratio - October 2003 5 Leeds PCTs Leeds Teaching Hospitals NHS Trust 3 Findings Benchmarking Data Networking 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. 4.5 4.1 4 4 4 3.8 3.7 3.6 3.5 3.5 3.5 3.5 3.4 3 2.9 2.8 2.6 FUN ratio 2.5 2.3 2.2 2 1.5 1 0.5 0 s rk ld s rd ry nd ds ns e l e tle am te ul ed ld al al fie Yo u ga fo H el re s la fie d rd sb gh ca Le ad ef rfi er re ld ro de er ew tin ew Sh oo hi Ai nd Br ar nd al C ot D H M N Su C Pi N ld fie ef Sh Hospital 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 figures. Follow-up to New Ratio - October 2003 Page 7 of 29 5 Leeds PCTs Leeds Teaching Hospitals NHS Trust 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: 12 10 8 Number of hospitals 6 4 2 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Number of consultants Teaching hospital non-Teaching hospital Page 8 of 29 Follow-up to New Ratio - October 2003 5 Leeds PCTs Leeds Teaching Hospitals NHS Trust 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. 25 number of consultants required for the catchement population stated 20 20 14.2 13.7 14.8 15 11.7 10 5 0 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. Follow-up to New Ratio - October 2003 Page 9 of 29 5 Leeds PCTs Leeds Teaching Hospitals NHS Trust 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. 6 B 5 4 FUN ratio 3 2 A 1 0 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, Non- 117 1.4 8(6.2 WTE) 500,000 4 community optometry Teaching clinics, staff grades Non- 112 1.35 3.2 N/A 3 None Teaching Nurse glaucoma clinics, direct access 132 1.2 Teaching 4 500,000 4 cataract with optom FU, shared care paediatrics Page 10 of 29 Follow-up to New Ratio - October 2003 5 Leeds PCTs Leeds Teaching Hospitals NHS Trust 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- specialities. 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. Follow-up to New Ratio - October 2003 Page 11 of 29 5 Leeds PCTs Leeds Teaching Hospitals NHS Trust 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: 45 40 35 30 Number of Units 25 20 15 10 5 0 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 disease. 321 Barriers that units perceive to implementing these strategies Number of Barrier units 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 Page 12 of 29 Follow-up to New Ratio - October 2003 5 Leeds PCTs Leeds Teaching Hospitals NHS Trust Number of Barrier units 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 Follow-up to New Ratio - October 2003 Page 13 of 29 5 Leeds PCTs Leeds Teaching Hospitals NHS Trust 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 pathways 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 pathways 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 pathways 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 Page 14 of 29 Follow-up to New Ratio - October 2003 5 Leeds PCTs Leeds Teaching Hospitals NHS Trust Clinic type: General Number of patient journeys identified: 9 (3 unfinished) Number of FU: NP Ratio Description pathways 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 pathways 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 pathways 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 5 Leeds PCTs Leeds Teaching Hospitals NHS Trust Clinic type: Paediatrics Number of patient journeys identified: 4 (unfinished) Number of FU: NP Ratio Description pathways 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 possible + 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). Page 16 of 29 Follow-up to New Ratio - October 2003 5 Leeds PCTs Leeds Teaching Hospitals NHS Trust 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. Cataract 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 fashion. Follow-up to New Ratio - October 2003 Page 17 of 29 5 Leeds PCTs Leeds Teaching Hospitals NHS Trust 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 difficulty. AMD 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 Cataract 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. AMD 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 Cataract 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 Leeds Teaching Hospitals NHS Trust 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 AMD 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. explanation. LVA appointment. LVA appointment. Social services Social services rehab/support Yellow background community based care rehab/support Blue background hospital based care arranged. arranged. 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. Paediatric 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 proficient. 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 attendance. 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 consultants. Follow-up to New Ratio - October 2003 Page 25 of 29 5 Leeds PCTs Leeds Teaching Hospitals NHS Trust Appendix 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 Appendix 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: Glaucoma 68A2. Glaucoma screen F45.. Glaucoma F4504 Ocular Hypertension Cataract F46.. Cataract 7265y Capsular Opacity Diabetes 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) ARMD 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 email@example.com Follow-up to New Ratio - October 2003 Page 27 of 29 5 Leeds PCTs Leeds Teaching Hospitals NHS Trust Abbreviations 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 References 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 Aug;6(3):273-9. 4 Establishing patient preferences for gastroenterology clinic reorganization using conjoint analysis. Moayyedi P et al. Eur J Gastroenterol Hepatol. 2002 Apr;14(4):429- 33. 5 Reducing non-attendance at outpatient clinics. Stone CA et al. J R Soc Med 1999 Mar 92(3):114-8. 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 Suppl):225-7. 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- 169. Follow-up to New Ratio - October 2003 Page 29 of 29
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