Draft service specification

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 Service               Community Ophthalmology Services
                       NHS Enfield
 Provider Lead         TBD

1. Purpose

 1.1 Introduction

This document outlines the Service Specification for the delivery of the Community Ophthalmology
Service service, setting out the requirements for a service for NHS Enfield

The aim of the Community Ophthalmology Service, is to improve the quality of services and clinical
outcomes, reduce waiting times and increase access for patients and provide value for money.

At present glaucoma care accounts for approximately 30-40% of all outpatient visits in ophthalmology
departments. Some 15-20% of new referrals are glaucoma related. Of this group 33% are confirmed
of having the disease, 33% are considered suspicious and require further follow up and 33% are
found to be negative. Therefore 66% could be described as inappropriate referrals and these patients
could be effectively managed in the community.

33% of all referrals to hospital for cataract surgery decided, or were advised, not to go ahead. Often
the risk of surgery was the pivot upon which marginal cases declined to go ahead. This was a wasteful
method of sifting the referrals. A smaller number had other eye disease accounting for the reduced VA
Initial findings show the numbers who now pass to the hospital and do not go ahead with the operation
has dropped from 33% to 2%, demonstrating a dramatic reduction in inappropriate referrals, and a
similar reduction in wasted clinical time at hospital

ARMD affects approximately 10% of the population of 66-74 year olds and this increases to 30% of
the population of 75-85 year olds. Extrapolated for Enfield this equates to approximately 5600 cases
of ARMD currently in Enfield. Of these approximately 10% (560) will have wet ARMD, the other 90%
(5040) will have dry ARMD.

The service will be pivotal to the achievement of reduced waiting times by offering more community
based services to patients, therefore reducing demand for secondary care and releasing that capacity
for those patients with more complex and urgent needs. The service will benefit patients by delivering
a more efficient and effective care pathway. The provision of alternative treatment settings will
support the reduction in demand for secondary care. Where onward referral to secondary care is
deemed necessary, the service will prepare patients to a higher level than was previously the case

The overall aim is to provide a safe, flexible and efficient community based ophthalmic service for
people registered with an Enfield GP.
  1.2 Aims

   i.   To provide a high quality ophthalmic service in locations closer to patient’s homes.

  ii.   To improve access and reduce waiting times for ophthalmic services whether they are seen in
        a hospital or community setting.

 iii.   To demonstrate a movement in the clinical threshold for accessing services for assessment,
        diagnosis and treatment from secondary into primary care.

 iv.    To address attrition rates from point of referral to treatment, ensuring patients are seen by the
        most appropriate healthcare professional in the most appropriate setting

  v.    To develop common pathways of care ensuring there is no unnecessary duplication, and
        promote the integration and coordination of services across primary care and accredited
        secondary care providers.

 vi.    To reduce the number of inappropriate referrals into secondary care.

vii.    To offer patients a choice of provider.

viii.   To provide a service which is evidence-based and value for money (VfM).

 ix.    To support and enable patients to manage their own conditions by providing a pro-active
        approach to self-management

  x.    To provide a service that is multi-disciplinary, is patient centred, and improves the patient

 xi.    To deliver a package of care that moves patients swiftly along an evidenced based pathway
        (with stepped approach and one-stop services where possible or appropriate)

xii.    To support an innovative approach to service delivery (i.e. extended working hours, new
        models of care, new technologies etc.)

This will be achieved by:
  Providing timely and effective triage of all new ophthalmic referrals.
  Providing timely access to specialist clinical expertise in primary care.
  Providing timely access to a comprehensive range of diagnostic and treatment services in
     primary care.
  Providing clear and unencumbered referral pathways for those patients who require intervention
     from other specialties or secondary care.
  Providing high quality performance information as defined by the specification to commissioners
     at prearranged and agreed intervals

  1.3 Evidence Base

There is considerable evidence to support the delivery of services in the community:

As the population ages, the incidence and burden of eye disease is set to increase. Many eye
diseases are chronic in nature meaning patients must be managed over the long term. In England and
Wales the number of cases of glaucoma, one of the most common chronic eye diseases, is likely to
increase by a third by 2021. The eye diseases in the UK with the highest numbers of people affected
and highest costs associated with their care are cataract, primary open angle glaucoma, age-related
macular degeneration, and diabetic retinopathy. Children’s eye problems of strabismus and amblyopia
have an incidence of up to 5% and 3% respectively and account for the majority of children’s
ophthalmic activity.

The Department of Health Commissioning Toolkit for Community Based Eye Care Services (2007)
specifically identifies several pathways that have the potential to be managed in primary care. These
include: glaucoma testing ophthalmology interface service, follow up, primary eye care acute referral
schemes, cataract monitoring, age-related macular degeneration review, and low vision services.
Management of some common childhood vision problems was also identified as care which can occur
outside of hospital by suitably qualified eye care professionals. Shifting of some pathways out of
traditional secondary care is also supported by the Royal College of Ophthalmologists, Association of
Optometrists and College of Optometrists.

 1.4 General Overview

The service will operate as two parts, which can either be provided as a joint service or be run side-by-
side with different providers:
• A specialist-led service offering triage of ophthalmic conditions, and developing into management of
more complex conditions over time. Patients will be referred into the service from other health
professionals, typically the patients own GP.
• An optometrist (or other applicable health professional) led service offering management of patients
with glaucoma whose condition is considered stable. Patients will either be referred in via their own
GP or secondary care consultant, where it is considered appropriate for those patients to be managed
in the community.
A senior clinician should have overall responsibility for the clinical oversight of this service.

 1.5 Objectives

Implementation of this service will meet the following national and local objectives:
Care closer to home (Our Health, Our Care, Our Say)
     This proposal will bring diagnostic and treatment services out of the acute sector and into the
        community. This will release activity from the main hospital site and move it so that it is closer
        and more convenient to the patient.
Access / choice
     At present patients have little choice as to where they wish to go if they need access to
        specialist advice. Although there are several acute sites within travelling distance of Enfield,
        choice will often be dictated by localness. This service will provide a new, realistic alternative
        with much shorter waiting times.
     This service will be able to offer quick access to services in the majority of cases, and so will
        ease the pressure on secondary care. In addition, the use of a primary care service will
        eliminate a great number of referrals, having the knock-on effect of reducing demand on
        hospital services.
Patient / user experience
     Patient experience is a very important component to this service and patient views expressed
        through satisfaction questionnaires will be taken seriously. Providers will need to have
        extensive experience in modifying services as a result of patient feedback and will utilise this
        previous experience when delivering the new ophthalmic service. Results from patient surveys
        will be used to ensure that the service is adapted wherever necessary to provide the best
        possible patient experience. The surveys will incorporate the whole patient experience from
        triage to patient booking to location convenience and facilities to clinician seen feedback.

 1.6 Expected Outcomes

The community specialist service will:
• Ensure that all patient records will be maintained and secured in line with national guidance and local
policies (for example, data protection act, confidentiality, Caldicott guidelines etc.) Providers will work
with the Trusts IM&T team to ensure the service is compliant

• Submit the outcome of the appointment and / or treatment plan to the patient’s GP within 5 working
days of the appointment taking place.

• Submit the following information to clusters and Practice Based Commissioners (on request) and the
Trust on a monthly basis:
     The number of referrals received and referral source
     Number of inappropriate referrals
     Number of new outpatients, by practice
     Number of follow up outpatients, by practice
     Number of patients referred to secondary care, by practice
     Number of patients discharged back to Primary Care, by practice and reason for discharge
     Details of procedures / interventions undertaken, by practice
     The DNA rate for appointments
     Average waiting time for new and follow up outpatients
     Ethnic monitoring

• Patient satisfaction surveys will also be undertaken on a monthly basis initially as the service
expands, then three monthly thereafter, with key outcomes being fed back to Commissioners.

• The following specific clinical data will also be available on a quarterly basis:
     Types of ophthalmic conditions seen.
     Numbers of onward referrals to secondary care consultants or optometrists.

• The impact on secondary care will also be monitored on a quarterly basis through the use of the
following formula:
      Number of patients referred per 1,000 pop per annum versus national rates

The glaucoma monitoring service will:
• Ensure that all patient records will be maintained and secured in line with national guidance and local
policies (for example, data protection act, confidentiality, Caldicott guidelines etc.)

• Submit the outcome of the appointment and / or treatment plan to the patients GP and / or
ophthalmic consultant within 5 working days of the appointment taking place.

• Submit the following information to clusters and Practice Based Commissioners (on request) and the
Trust on a quarterly basis or sooner if needed.
     The number of referrals received and referral source
     Number of inappropriate referrals
     Number of patients seen for first review
     Number of patients requiring rapid access
     Number of helpline calls
     Number of patients discharged from the service and reasons for discharge
     Number of patients referred back to Secondary Care and reason for referral
     The DNA rate for appointments / monitoring
     Number of domiciliary visits
     Levels of prescribing
     Ethnic monitoring
• Patient satisfaction surveys will also be undertaken with questionnaires sent to all patients
throughout the course of the pilot, with key outcomes being fed back to Commissioners.

• The following specific clinical data will also be available on a quarterly basis:
     Types of ophthalmic conditions seen
     Numbers of onward referrals to multi disciplinary team / other specialties
     Numbers of investigations, procedures or other interventions

• Disease activity outcome data will be provided from annual reviews

• The impact on secondary care will also be monitored on a quarterly basis through the use of the
      Secondary care new patient wait times, availability of rapid access appointments, reduced
        secondary care follow up activity and cost savings to the Trust for follow up and drugs.

In addition, the quality standards outlined in the business case will be measured and monitored, and
used to improve the service where appropriate.

2. Scope

2.1 Service Description

Triage would be carried out in SCAS by the clinicians who staff the new service with patients, where
appropriate, allocated to the community system for the most appropriate treatment in line with the
proposed ophthalmic pathways (Appendix 1).

The service will treat patients suffering from a range of acute eye conditions including:
    Blurred vision
    Watery eyes
    Dry eyes
    Lid lesions
    Floaters / flashing lights
    Blepharitis
    Field defects
    Retinal lesions
    Chalazion
    Corneal Abrasion
    Epiphora
    Ingrown Eyelash
    Pingueculum
    Pterygium
    Recurrent Erosion
    Squint/Amblyopia

Specific conditions to be treated are:

 Screening for suspected glaucoma or ocular hypertension per agreed criteria Follow up of stable
 primary open angle glaucoma per agreed protocol
 Referral refinement and post surgical follow up per agreed protocol – option for complete cataract
 Age Related Macular Degeneration:
 Initial screening for Wet versus Dry AMD and adherence to two week referral to treatment
 requirement for Wet AMD. Management of Dry AMD including low visual aid assessment and
 registration of visual impairment if appropriate and information and support
 Orthoptic service to children with vision / eye movement difficulties to include primary and
 secondary screening, community orthoptic service, community joint orthoptic/optometry service
 Support to special schools if required

Patients will be seen in a community setting i.e. an optometrist or GP practice by an OPwSI, GPwSI or
acute consultant supported by an ophthalmic nurse specialist. For paediatrics the community setting
may also include school, nursery, children’s health centres and they will be seen by an Orthoptist
and/or an Optometrist. Governance will be provided by a secondary care ophthalmology consultant.
All patients who meet the inclusion criteria will be referred to the service for triage / treatment / onward
referral. The service will operate as a network from a mixture of community settings.
Providers will need to purchase, maintain and replace as necessary all relevant equipment required to
provide the service. As a minimum, this is expected to include:

      Humphrey visual field machine (or equivalent threshold visual field screener) and printer
      Slit lamp
      Applanation tonometer
      Ophthalmoscope
      Amsler charts
      Epilation equipment
      Diagnostic drugs (mydriatics, stains, local anaesthetics, etc)
      Volk lens

NHS Enfield currently provides a minor eye conditions service provided by 6 local Optometrists taking
referrals directly from GP’s, self referrals or referrals from other Optometrists. The Provider would be
expected to encompass this service providing clinical leadership and governance and further
developing the service as required. Further details of this service can be found in Appendix 3.

2.2 Accessibility/acceptability

The service will be delivered from a minimum of two sites across the cluster area so should provide
good accessibility to patients

The service will see any patients who are registered with a NHS Enfield general practice, and who
have a non- urgent ophthalmic condition as listed in section 3.

2.3 Whole System Relationships

The service will link with the patients own GP, and accurate, timely communication will be expected
between providers and GPs. Similar communication will be maintained with the patient, and each
patient treated by the service will be informed at each stage of what will happen during the treatment
pathway. The service providers will also maintain strong working relationships with secondary care,
and patients will expect to be seen by their secondary care consultant annually as
Part of their package of care. Secondary care colleagues will be kept informed and will have access to
all the information gathered by the provider during previous appointments.
2.4 Interdependencies

The service will rely on building activity to the planned capacity levels, and as such will be dependent
on referring clinicians being aware of the service and the appropriate patients to be referred into the
service. Providers will market the service sufficiently to build this knowledge and awareness.

2.5 Sub-contractors

Providers may sub-contract parts of the service, however will remain the accountable body with the
commissioning body for all monitoring against the service specification.

2.6 Relevant networks and screening programmes

     Providers will ensure that all GPs within the boundaries of the service are aware of the service
      itself and of the referral mechanisms for referring patients into the service. The following
      considerations need to be in place prior to the service commencing:
     All clinicians, nurses and administrative staff complete a full induction and are conversant with
      the relevant services, policies and operational procedures
     Provide evidence of the competency of all staff in the clinical conditions included in this service
      specification, including working with vulnerable adults
     Ensure CRB checks are conducted and professional registration is in place
     Ensure that staff comply with the standards of conduct of their relevant regulatory body
     Ensure the availability of suitably qualified staff to meet the maximum waiting time and for
      demonstrating their ability to deliver the service
     Determine whether the personnel providing the service through the contract have appropriate
      personal indemnity cover to meet, in full, claims made against them as individuals. Providers
      must have such personal indemnity cover. Proof of cover of the provider must be submitted to
      the Commissioners
     Ensure that managers and employees receive appropriate training and guidance in
      respect of equality and diversity and in particular the application in recruitment and
      selection. Equality and diversity should be included in the induction training for all new
     There must be a complaints procedure in place.
     Prescribing requirements must be arranged through the Trusts Medicines Management Team

     3. Service Delivery

3.1 Service Model

The current secondary care ophthalmology case load can be divided into two parts: new referrals for
suspected ophthalmic conditions and follow up and management of patients with ongoing eye disease
e.g. glaucoma. This part of the proposal deals with the assessment of new referrals and those follow-
ups for stable conditions.

New Referrals

Following paper triage of new ophthalmic referrals assessment and/or treatment of patients presenting
with conditions specified in 2.1 will be undertaken by the Community Ophthalmic Service

Follow Ups
Follow up appointments can be sub-divided into 2 domains of activity.
1. Follow up after a new patient assessment/following treatment.
2. For patients identified with an ophthalmic condition, long-standing, regular follow-up appointments.

Many patients with glaucoma who are stable attend secondary care for routine assessment and
monitoring. Patients diagnosed with glaucoma and who require follow up can be divided into three
domains of activity:
1. Patients established and stable who require monitoring at programmed intervals.
2. Patients with established disease but whose disease is unstable and requires ongoing treatment.
3. Patients with new onset eye disease who have yet to have a management plan established and
Appendix 2 details the RCOphth definition of stable glaucoma.

Patients diagnosed with Macular Disease can be divided into five domains of activity:
1. Fast track referral (from optometrist or GP) to specialist treatment centre
2. Rapid assessment and where necessary treatment (either one-stop or two-stop service)
3. Information and support, including sign posting to local support groups (e.g. Macular Disease
4. Referral to low vision and rehabilitation services that are patient centred and reflect a multi-
disciplinary and multi-agency approach.
5. Certification/Registration as blind or partially sighted (severely sight impaired/sight impaired)
The Community Ophthalmic Service Provider will assess


All children between ages 4 and 5 and a half should be offered primary screening i.e. screened in their
schools, in addition to secondary screening (i.e. Orthoptist review of those children identified as
requiring further input by the GP/ Optician/ Health Visitor, or other health professional). Those in need
of further Ophthalmology involvement should then either be reviewed by community Orthoptists or
referred to secondary care or local opticians, depending on need. This ensures children are seen as
close to home or school as possible and by the appropriate people.

3.2 Pathways

Care pathways will be in line with existing secondary care pathways, however with a different provider
and service delivery location in place to recognise the community setting. Appendix 1

   10. Referral, Access and Acceptance Criteria

4.1 Geographic coverage/boundaries

The service will accept referrals from general practitioners and allied health professionals from across
the NHS Enfield area. The provider is required to offer a service to all eligible patients registered with
an Enfield GP. The service should be delivered in various locations throughout Enfield so that they are
easily accessible for all residents.
                           Chase Farm
                                                                                     10                8

                                                     17                    2
                                                 16                              1        11
                                                 20 21 18
                                                 19                              7
40                                                                                   6
          48               46                                    12              4
                                                           36                  25b
     51                                               25 24                          14

                                                      32        33
                            45 42                           26        27
                47          49             41
                                                35 34
                                50                    30               29
           37                                               28
                           39        44                               22
                                                                23 31

  North East (Cluster List Size)   94,122       North West (Cluster List Size)   43,898
      1. Brick Lane Surgery                     16. Abernethy House Surgery
      2. Carterhatch Lane Surgery               17. Carlton House Surgery
      3. Curzon Avenue Surgery                  18. Southbury Surgery
      4. Dean House                             19. Town Surgery
      5. DMC Enfield Lock                       20. White Lodge Medical Practice
      6. Eagle House Surgery                    21. Willow House Surgery
      7. East Enfield Practice
      8. Enfield Island Surgery
      9. Forest Primary Care Centre (x4)
      10. Freezywater Primary Care Centre
      11. Green Street Surgery
      12. Lincoln Road Medical Practice
      13. Moorfield Road Health Centre
      14. Nightingale House Surgery
      15. Riley House

  South East (Cluster List Size)   65,865       South West (Cluster List Size)   94,354
     22. Angel Surgery                          37. Arnos Grove Medical Centre
     23.. Boundary Court Surgery                38. Bincote Road Surgery
     24. Bush Hill Park Medical Centre          39. Bowes Medical Centre
     25. Bush Hill Park Medical Practice        40. Cockfosters Medical Centre
     25b Bush Hill Park MC (Branch)             41. Connaught Surgery
     26. Chalfont Road Surgery                  42. Gillan House
     27. Evergreen Primary Care Centre (x6)     43. Green Lanes Surgery (x3)
     28. Dover House Surgery                    44. Grenoble Gardens Surgery
     29. Edmonton Medical Centre                45. Grovelands Medical Centre
     30. Green Cedars Surgery                   45b. Grovelands (Branch)
     31. Ingleton Road Surgery                  46. Highlands Practice
     32. Keats Surgery                          47. Jaina House Surgery
     33. Latymer Road Surgery                   48. Oakwood Medical Centre
     34. Morecambe Surgery                      49. Park Lodge Medical Centre
     35. Palm Medical Centre                    50. Rochdale Surgery
     36. Trinity Avenue Surgery                 51. Southgate Surgery
                                                52. Woodberry Practice

  4.2 Location(s) and Access

The service will operate from a range of facilities (GP practices, Schools, Nursery’s, Health Centres or
high street optometrists) from across the geographical area in order to provide a service as close to
the patients home as possible. There will be the facility for glaucoma monitoring appointments, where
appropriate, to be delivered close to the patients home. Locations of sites should be accessible to
public transport and parking facilities. Existing sites should be utilised where possible. Sites that are
not currently used for NHS service delivery must demonstrate compliance with all relevant building
regulations, DDA compliance and must be fit for purpose, clean and comfortable. Premises must meet
general health and safety requirements.

The service will be delivered from a minimum of two sites from each cluster area so should provide
good accessibility to patients

The service will be available initially across the range of Monday to Friday, 8.30am – 5pm. Patient
feedback will be monitored to identify whether there is a demand to provide appointments outside of
these core hours. One Saturday service will be commissioned across the PCT area to operate
between 8.30 –12.30pm.

The service must be responsive to the needs of patients, and this must be reflected in the hours that
the service is open for business. As a minimum the community service must be available beyond
normal office hours if required. Service availability will be a key criterion against which potential
providers will be evaluated. Services will operate every week of the year unless agreed in advance by
the commissioner. The service could be available on weekends or Public Holidays. The provider and
commissioner will agree a schedule of clinics and working days for the service for the duration of the

The location would need to be accessible to patients and preferably delivered in primary care settings.
Patients with special needs (e.g. disability or language may be identified during the referral/booking
process and the necessary arrangements made. If this has not occurred it will be the responsibility of
the provider to identify these needs and make the necessary arrangements for support services which
will be provided and funded by the PCT.

  4.3 Referral criteria

The service will see any patients who are registered with a NHS Enfield general practice, and who
have a non- urgent ophthalmic condition.

Patients suffering from a suspected ophthalmic condition will be referred by their GP or by an AHP to
the specialist triage / screening element of the community service for initial assessment and possible
onward treatment. Patients needing glaucoma monitoring will either be referred by the patients GP or
by their secondary care consultant. The service will also identify, through clinical audit of patient
information, patients who are currently being seen in secondary care who could be successfully
managed in primary care.

  4.4 Referral route

The SCAS team would be the single point of entry for the receipt of all referrals from Enfield practices
and from secondary care clinicians. The PCT commissioners plan is to achieve 100% of referrals
through SCAS at a pre- agreed point in 2010-11. The PCT will commence discussions with Provider
Trusts regarding the management of referrals that are directed to secondary care without having first
being triaged within the SCAS. It is expected that the SLA will support a system whereby the referral is
passed back to the SCAS for review.

  4.5 Exclusion Criteria

The service is not available to:
    Patients not registered with a NHS Enfield GP
    Patients who require emergency treatment
    Patients re referred with post operative or post traumatic complications
    Treatment that should be provided under a standard GMS or PMS contract
    2 week cancer referrals
    Diabetic retinopathy screening

The service will assess all referrals received before accepting them for treatment. Conditions and
treatments that could reasonably be expected to be treated by a GP will be returned to the referring
The exclusion list will be reviewed in 2011 and any adjustments will depend on the clinical skill
mix of service providers.

4.6 Response time and prioritisation

Referrals should be dealt with on a first-come, first-served basis, irrespective of the location of the
practice to which the patient belongs. Paper triage of referrals will take place within 24 hours of receipt
of the referral by SCAS. Once the referral has been accepted, the service will contact patients within 1
working day and offer them an appointment within 21 days of the referral being accepted. A choice of
appointment days and times will be offered and patients will have the option of booking appointments
outside the 21 day period for eventualities such as holidays. A letter detailing the diagnosis, treatment,
prognosis and any other supporting advice will be returned to the GP within seven days of clinic

The service will also provide advice and guidance to patients up to 28 days after they have been
discharged by the service – patients can telephone, write or email the service and expect a clinical
response within two working days. If further advice and guidance is required after this period, patients
will be required to re-visit their GP for re-assessment. The service will also provide advice and
guidance to GPs to support better primary care management of ophthalmic conditions. GPs will be
able to email the service directly, for advice and expect to receive a response within three working

Patients who DNA an appointment will be sent one further appointment. Should that patient fail to
attend both appointments for then they will be returned to the care of the referring clinician, with an
explanation of the reasons for the return. Patient referrals will be logged as part of the data capture to
ensure that patients are not lost in the system.

   10. Discharge Criteria & Planning

Patients will only be discharged from the service when it is clinically appropriate to do so. They will
either be discharged back to the care of their own GP, or to secondary care ophthalmology consultant
services. In either case, a full report will be prepared and sent to the relevant clinician. Discharge
letters from the service will be sent back to the patients own GP within 7 days of discharge. Copies will
also be sent to the patient and to the relevant secondary care consultant where appropriate.
Discharge letters can be sent by post or from / to secure email accounts.

Before a child is discharged from the service after any form of treatment or advice, where appropriate
the referring Agent is informed; any advice, care plans etc are shared with other agencies actively
involved with child and family with the consent of the parent / guardian; the parent / guardian is
informed of contact details and processes for re-referral back into the service if necessary.

   10. Self-Care and Patient and Carer Information

The service will provide advice and guidance to patients up to 28 working days after they have been
discharged by the service – patients can telephone, write or email the service and expect a clinical
response within two working days. If further advice and guidance is required after this period, patients
will be required to re-visit their GP for re-assessment. Patient information will be held electronically,
and the information will be backed-up to secure servers on a regular basis. The recording system
must be sufficiently robust to stand alone from the providers own system for recording registered
patients, particularly when seeing patients from other practices. The Commissioner will provide a
recording template including the requirements of the Commissioner, and the Provider will use this to
record activity of the service.

The Provider will have sufficient confidentiality policies in place to ensure that only appropriate
personnel from the Provider have access to the patient-level data. The Provider will be expected to
provide a copy of their own complaints procedure.
Where possible and when it is appropriate to do so children are actively encouraged to self manage
their condition to enable them to become independent and to reach their full potential. This is achieved
with the use of:
• Management Care plans
• Advice sheets
Where the child is too young it is expected that the parent / guardian would assume the responsibility
of implementing therapy with the therapists advice and support.

7. Quality and Performance Indicators

Full records of each patient contact should be maintained in such a way that aggregated data and
details of individual patients are readily accessible in electronic and / or written form. Providers should
maintain access to the database as part of the regular service reviews, which will be carried out in
conjunction with the NHS Enfield on a minimum of a quarterly basis. Providers will gather information
on activity on a weekly basis, and provide monthly reports to commissioners on activity carried out
within the community eye care service. Providers will carry out an annual audit and review of the
service which will be distributed to practices that refer patients into the service. This audit and review
will also be distributed to local commissioners as part of the annual review of the service.

Providers will be subject to an annual governance review.

 Quality &                 Threshold                    Method of                Consequence of
 Performance                                            Measurement              Breach

 Service user              20% return of                Patient                  None
 experience                questionnaires               satisfaction

 Service user              10% cancellation             Provider                 None
 experience                rate due to diagnostic       information
 returns                   tests not being taken /
                           available from referring

 Access                    100% of patients to be       Provider                 None
                           triaged within 2 working     information
                           days (and prior to patient   returns
                           being seen in clinic)
 Access                    All patients contacted       Provider                 No
                           within 1 working day of      information
                           triage                       returns

 Access                    All patients offered         Provider                 None
                           appointment date within      information
                           21 working days              returns

 Patient safety            80% of patients seen to      Provider                 None
                           have been triaged prior      information
                           to attendance and            returns
                           seen as appropriate in
                           the community service
 Patient safety            Clinicians delivering      Performance &            Service Suspended
                           Service governance         Governance checks
                           Arrangements collapse

 Data quality              Monthly activity returns   Provider                 1 month delay in
                           not supplied within 5      information              payment
                           working days               returns

                           90% of all reception       Provider
 Screening                 children have              information              None
                           Orthoptic check in         returns
                           1 year at school

8 Activity

It is anticipated that a minimum of 40% of outpatient attendances will be moved from secondary care
into the new community based service. This equates to approximately 12,000 outpatient attendances
per year. It is also estimated that approximately 3500 reception age children will need to undergo
primary screening per year.

The planned activity will be used as a baseline, and activity carried out up to 10% above the plan will
be funded by the commissioner. Activity carried out above this upper threshold will not be chargeable.
Thresholds will be calculated on a monthly basis to ensure consistent activity and volumes are
presented to the commissioner. Where activity falls below the planned levels, payments will be based
on actual activity. There will be no minimum payment guarantee, and the risk of there being
insufficient activity sits with the provider.

    10. Continual Service Improvement Plan

Service improvement will be driven primarily by patient feedback, however the service will also be
evaluated on a six-monthly basis, and this evaluation will form the basis of the iterative changes
needed to the service during the pilot period. Findings from the pilot period will drive the service
specification for the final service.

    10. Prices & Costs

Provider to specify costs at rate below PbR tariff for 2010/11.
                                                                                           Appendix 1
                                                   Cataract Pathway
           Option 1                                                                          Option 2

     COMMUNITY EYE SERVICE/COMMUNITY                                                 COMMUNITY EYE
     OPTOMETRIST DIAGNOSIS OF CATARACT -                                             SERVICE/COMMUNITY
     surgery indicated, patient confirms surgery                                     OPTOMETRIST DIAGNOSIS OF
     wanted                                                                          CATARACT - surgery indicated,
                                                                                     patient confirms surgery wanted
                                                                                     Pre Assessment
                                                                                     Direct Listing for surgery


                                              PATIENT LISTED FOR SURGERY – PRE
                                              ASSESSMENT TAKES PLACE

                                      PATIENT ADMITTED FOR DAY CASE SURGERY

PATIENT                                             HOURS

                                                   POST OPERATIVE REVIEW BY
                                                   COMMUNITY EYE SERVICE 2-4 WEEKS

                                                      PATIENT DISCHARGED
                                           Glaucoma Pathway for New Referrals

                                          Community Optometrist/Community Eye Service
                                                  Routine eye test? Glaucoma

Pressures <25 or less                                                    Pressure >21                      Cup asymmetry of
Normal disc cupping            Pressures >24 with no risk factors        Abnormal disc cupping             >0.2 with normal IOP
Normal fields                                   OR                       Visual field defect               and fields:
No Risk Factors                >21 with one or more risk factors
                               Risk factors =                                    Do not repeat fields     Does not require
Do not refer, review                 Family history of                           or pressures             either referral or
patient routinely                        Glaucoma                                Complete EPCT            repeat tests but
                                     Myopia                                      referral form and        should be monitored
                                     PHM Diabetes                                refer patient            in one year through
                                     From an Asian or Afro                       straight to HES          GOS according to local
Do not refer. Review
                                         Caribbean ethnic group                  Patient is not part of   protocol (see
patient again in one
                                                OR                                the Scheme               guidelines)
 year under GOS 5.2
                                 Optic disc appearance alone ie
  according to local
                                      cupping or suspicious
Payment triggered for
                                        Visual field defect
 repeat tests but nor
for review in one year
                                   IOP >21 and discs cupped

                               Repeat pressures and fields
                               within 10 days.

                                                         Pressures >24with no risk factors
                                                         >21 with one or more risk factors
Pressures <25 for patients with no risk
<21 for patients with risk factors and
normal fields
                                                     Refer to Hospital Eye Service via SCAS
                                                     using approved referral form.

                This framework does not include every instance in which the patient should be
                  referred and is not intended to be a substitute for professional judgement.
                Consideration should be given to inter-eye symmetry and borderline changes,
                 from previous clinical findings. Patients can be retested in 12 months using
                    GOS under the local protocol if they are borderline. If in doubt refer.
                                             Paediatric Pathway

                                          Primary & Secondary Screening
                                               Orthoptist & HCWA

Patient seen by HCP and referred to                                       Children in area invited for screening at
           HES via SCAS                                                                 school/clinic

       Paper triage                                        Abnormal                                    Normal

            HES                                      Community Eye Service                                Discharged

                              Refer to Optometrist                            Follow up by
                                                                             Community Eye
                AMD Referral and Treatment Pathway

                 Patient seen by Community Optometrist, GP, Eye
                           Casualty, A&E, Local Eye Unit

                        Community Eye Service Fast Track
                       Macular Clinic via dedicated fax/email
                           Assessment within 1 week

   Supportive Care:                                      Designated Treatment Provider
         LVA                                                  via dedicated fax/email
Assessment & Support                                 Assessment and Treatment performed
     Counselling                                      at this visit within 2 weeks of referral
  Patient Education

                                                          Community Eye Service Follow Up
                                                           APPENDIX 2

                         Stable Glaucoma

The Royal College of Ophthalmologists defines stable glaucoma as:

   No change in the management of the patients glaucoma for two

   No new symptoms for two years which could be attributable to
    progressive visual deterioration, such as a drop in acuity or
    subjective change of a paracentral visual field defect

   An intraocular pressure remaining below a level satisfactory for
    the individual patient for two years

   No change in the optic disc appearance for two years. This
    should preferably be based on good quality optic disc
    photography undertaken in the HES at baseline

   No significant change in visual field over two years
                                                                                APPENDIX 3


The PCT has developed a programme of service redesign with the objective of reviewing and
improving services, bringing services closer to home and ensuring better value.
Ophthalmology was identified as one of the areas to be looked by the Service Redesign
programme. As part of this project a Local Enhanced Service (LES) similar to Haringey and
Islington PCT pilot has been agreed, for approved providers to review minor eye condition.

If you have a patient who has any of the following “suspected” eye condition they can be seen
by the locally approved Optometrist for the pilot scheme (Detailed in list of Approval Enfield
Optometrists). All of the Optometrists providing this service have received training in the
operational aspects of the scheme by the PCT.

Appendix 1 clearly illustrates the patient pathway for their treatment

Conditions included as Minor Eye Conditions:

        Conjunctivitis; allergic
        Conjunctivitis: bacterial
        Conjunctivitis: seasonal and perennial
        Corneal Abrasion
        Dry Eye
        Ingrown Eyelash
        Recurrent Erosion
        Red Eye *

The list of approved Optometrists will need to be given to the patient and they can then
choose which of the approved optometrist he/she would like to go to.

The provider will:

       Provide advice and support to people on the management of minor eye conditions,
        including where necessary treatment of the minor eye condition, for those people who
        would have otherwise gone to their Enfield GP.
       Under this scheme, will only see patients referred by an Enfield GP hence the
        scheme is only applicable for patients registered with an Enfield GP.
       Provide advice on the management of the aliment in line with approved protocols
       Refer patients directly to hospital if necessary (offering choice)
       Will maintain a record of the consultation and any medication that is given.
       Provide the patient where appropriate with medication in line with agreed protocols.
       Participate in an agreed audit of the service with NHS Enfield as part of the

*If a patient presents with red eye after 4.30pm that you do not consider can clinically wait until
the next morning to be seen please refer to A&E
    Community Ophthalmology Service Specification
             Patient Pathway for Minor Eye Conditions
                         Community Service.


                                GP PRACTICE/


REPORT ON                  APPROVED OPTMETRIST                                 ONWARD
DIAGNOSIS             DIRECT REFERRAL TO OPTOM                                 REFERRAL
AND                                                                            Direct Referral
MANAGEMENT                                                                     by Optometrist
GOES BACK                                                                      to hospital of
TO THE GP.                                                                     patient choice

               DIAGNOSIS/                        NO TREATMENT
               ADVICE/MEDICATION                 NEEDED

    Conditions included as Minor Eye Condition (Suspected)

    Blepharitis                                     Dry Eye
    Conjunctivitis: allergic                        Ingrown Eyelash
    Conjunctivitis: seasonal and perennial          Chalazion
    Conjunctivitis: bacterial                       Corneal Abrasion
    Epiphora                                        Pingueculum
    Pterygium                                       Recurrent Erosion
    Red Eye

    Alison Mitchell-Hall                              21                         21/05/2011
Community Ophthalmology Service Specification
                          Red Eye Referral Guidelines

The GP normally has options to take when a patient presents with an eye problem.

    1. Treat the eye condition himself
    2. Refer urgently when appropriate
    3. Refer routinely if non urgent

The difficulty has always been that it is often hard to differentiate between a red eye
that is just conjunctivitis, and one which is iritis, keratitis or episclerits which have
more serious consequences, when there may not be access to a slit lamp
microscope, staining agents and a darkened room.

There are many eye conditions that could be more easily assessed with a slit lamp
microscope, diagnostic drugs, visual field analysers, tonometers etc, which are
standard equipment in an optometrists consulting room.

The minor eye conditions scheme has been set up to help GPs refine the eye
problems that come into their surgery by having an extra choice of sending the
patients to accredited optometrists. It is meant to compliment the urgent triage
scheme at the Eye Hospital and ensure patients receive swift appropriate treatment
in the community where possible.

Red eye is a common presentation in primary care and in the emergency
department. Most cases will be due to relatively trivial problems.1 A small proportion
of cases need urgent treatment. The challenge lies in discerning one from the other.

There are a number of ways of 'classifying' a red eye but perhaps the most practical
is whether there is associated pain or not. Intrinsically associated with this is the
visual acuity which must be measured for both eyes of all patients. Where this is
impaired, it is absolutely vital to rule out serious pathology.

Assessment of the red eye

Patients commonly present with a red eye with no history of trauma

The clinical features of concern are:

        Pain in the eye (other than just a FB sensation)
        Decrease in visual acuity
        Abnormal pupil reactions
        Corneal abnormalities

The basic structure is no different than for other systems but take particular note of
the following:

        History of presenting complaint - the time and speed of onset, ocular
        associations (e.g. photophobia, blurry vision, discharge etc), systemic
        associations (e.g. headaches, nausea, rash on the forehead) and what the
        fellow eye is up to - a surprising number of patients fail to tell you about
        symptoms there. Specifically enquire about trauma, however minor it appears
        to have been.
Alison Mitchell-Hall                            22                              21/05/2011
Community Ophthalmology Service Specification
        Past ocular history - similar episodes, other episodes, surgery, 'lazy eye'
        (which would guide you as to whether the recorded visual acuity is worrying or
        not). Do they or have they worn contact lenses and ask about their level of
        hygiene (do they forget to clean them? Forget to take daily disposables out at
        Social history - has this nursery school teacher been in contact with a young
        child with a red/sticky eye? Will this elderly patient manage intensive eye
        treatment on their own? Extra support may need to be thought about to
        prevent admission.

It is essential to record the visual acuity (VA) and carry out a careful anatomical
examination (start anteriorly and work your way backwards). Pupils and their
reactions should also be checked (look for the distorted or small pupil of acute
anterior uveitis or the mid dilated fixed pupil of acute angle closure glaucoma).

If no ocular causes of a red eye emerge, consider potential systemic causes that
would prompt a review of the patient's past medical history ± a full physical
examination. Scleritis (and much less commonly, episcleritis) is frequently associated
with connective tissue diseases - particularly rheumatoid arthritis, gout, syphilis
and less commonly, tuberculosis, sarcoidosis and hypertension.

Alison Mitchell-Hall                            23                             21/05/2011
Community Ophthalmology Service Specification
The acute painful red eye

Suspected              Common symptoms              Common signs                 Referral
condition                                                                        urgency

Acute angle            Severely painful,        Decreased VA, hazy            Refer
closure                haloes around lights,    cornea, fixed, semi-          immediately to
glaucoma               may be systemically      dilated or oval pupil.        A&E.
                       unwell (nausea,
                       vomiting, headache).
                       Usually > 50yo.

Keratitis              Photophobia, foreign     VA depends on exact           Refer to
                       body sensation ±         nature of problem -           Approved
                       history of contact       peripheral lesions may        Optometrist
                       lens wear ± previous     cause little change but       within 24 hours.
                       episodes (e.g. herpes    some decrease is
                       simplex infection).      expected. Corneal
                                                defect on staining ±
                                                hypopyon (pus seen in
                                                anterior chamber).

Acute                  Photophobia, blurred     VA may be reduced,            Refer to
anterior               vision, headache,        redness more localised        Approved
uveitis                pain on                  around corneal edge           Optometrist
                       accommodating. May       (ciliary injection), pupils   within 24 hours
                       have been                may be constricted or
                       unresponsive to          irregular. When severe,
                       previous treatment for   white cells precipitate
                       conjunctivitis.          on corneal endothelial
                                                surface (seen as white
                                                clumps - keratic

                                                                              Patient needs
Trauma e.g.            Pain depends on type     Depends on trauma.
                                                                              to have a full
foreign                of trauma, severity
body (FB)              and location.                                          slit-lamp
                                                                              examination -
                                                                              immediately if
                                                                              risk of serious

Alison Mitchell-Hall                               24                               21/05/2011
Community Ophthalmology Service Specification

The acute non painful red eye

  Suspected                Common                Common signs                Referral
  condition               symptoms

Conjunctivitis         Discomfort               Normal VA unless         Refer to
                       (moderate to             corneal                  Approved
                       severe pain -            involvement, uni or      Optometrist if
                       suspect more             bilateral, discharge     fails to settle or
                       serious pathology),      in infective             respond to
                       photophobia rare         conjunctivitis,          treatment (over
                       unless severe from       follicles or papillae,   7-10 days) or if
                       of adenoviral            may be eyelid            suspicion of
                       infection which may      swelling ±               herpetic infection.
                       involve the cornea,      conjunctival
                       discharge ± history      oedema.
                       of contact ± history
                       of allergen

Episcleritis           Mild discomfort,         Normal VA,               Refer to
                       few symptoms.            localised patch of       Approved
                                                redness/injection        Optometrist if
                                                which blanches on        there is more
                                                application of a drop    than slight
                                                of phenlyepherine        discomfort or if it
                                                2.5%. No discharge.      fails to settle
                                                                         over ~ 1 week.

Subconjunctival        May be                   Blood under              Refer to
haemorrhage            spontaneous or           conjunctiva              Approved
                       traumatic, can           covering part or all     Optometrist if
                       occur after              of eye which is          traumatic. If not,
                       prolonged                otherwise quiet with     check BP in
                       coughing.                normal VA.               elderly patients
                       Asymptomatic.                                     (can occur with
                                                                         and reassure:
                                                                         should resolve
                                                                         over a fortnight.

This is an inflammation of the full thickness of the sclera and usually presents with a
red eye. Its presentation is insidious, however, with the key symptom being a gradual
onset of severe and boring eye pain which may radiate to the forehead, brow or jaw.
Alison Mitchell-Hall                              25                              21/05/2011
Community Ophthalmology Service Specification
Over time there will be a progressive onset of photophobia and vision will become
gradually impaired. Suspect this in the older patient (particularly from the sixth
decade onwards) with systemic conditions such as connective tissue disease, gout
and previous herpes zoster ophthalmicus. These patients need referring to the
hospital eye service within 24-48 hours for treatment under ophthalmological
A rare but potentially devastating condition which can occur post-operatively (within a
few days or delayed a month or more post surgery), post trauma, in an acutely
septicaemic patient, immunocompromised patient or in intravenous drug abusers.
The patient presents with a red eye, decreasing VAs and pain. Although pain is very
common, it is not invariable. There will be a hypopyon in the anterior chamber as well
as a severe anterior chamber reaction (this will be hazy with fibrin and inflammatory
cells) and there may be associated conjunctival chemosis and eyelid oedema.
These patients need to be urgently referred to A&E.

The non-acute red eye – refer to Approved Optometrist if further assessment
Adnexial causes
    Blepharitis
    Trichiasis/distichiasis
    Floppy eyelid syndrome
    Lagophthalmos
    Dacryocystitis
    Canaliculitis
    Acne rosacea

Conjunctival causes
   Medication toxicity
   Injected pinguecula - a pingueculum is a common, innocuous lesion seen as
      a cluster of yellow-white deposits (usually in a triangular formation with the
      base adjacent to the cornea) arranged temporally or nasally to the cornea. If it
      becomes inflamed (pingueculitis), it becomes red and may be slightly
      elevated. Depending on the symptoms (mild to marked discomfort), the
      patient may benefit from a short course of weak steroids.
   Other causes include Stevens-Johnson syndrome, cicatricial pemphigoid
      and conjunctival neoplasia (rare).
Corneal causes
It is unusual for a corneal condition to present as a chronic red eye problem.
Presentation of long-standing conditions tend to be acute with some or all of the
usual symptoms relating to corneal problems (pain, photophobia, may be reduced
VA) but recurrent. Some examples include the presence of a pterygium which has
become inflamed, recurrent corneal erosion syndrome and cases of recurrent
keratitis (such as marginal keratitis or herpes simplex infection). Patients are often
familiar with their condition and its management.
Other causes

        Dry eye syndrome
        Carotid-cavernous sinus fistula
        Cluster headaches

Alison Mitchell-Hall                            26                            21/05/2011
PART 1 & 2 : To be completed by GP Surgery (then hand it to patient to
 Community Ophthalmology Service Specification                                                           PART 3 : To be completed by Optometrist
take to Enfield Optometrist, marked below)
                                                                                                         Patient Consultation Details
Patient Name                ____________________________
 k                                                                                                               Advice Only given
Gender                      MALE / FEMALE (Pls. Circle)                                                          Advice and Prescription – Patient Discharged
                                                                         Practice Stamp                          Advice and Prescription – Patient needs follow-up
Ethnicity                   ____________________________                                                         Direct Referral to Secondary Care

Practice Number             ____________________________                                                 Diagnosis : _________________________________________________________
NHS No                      ____________________________                                                 Management : ______________________________________________________
                                                         VOUCHER VALID FOR                               __________________________________________________________________
Date of Birth               ____________________________ THREE DAYS FROM                                 __________________________________________________________________
                                                         THE DATE OF
Date of Referral            ____________________________ REFERRAL
                                                                                                         Medication Supplied
Referring GP Name           ____________________________
                                                                                                         Medicine                                Quantity Supplied

PART 2 : Please mark the suspected condition for referral. (Tick
as appropriate)
         Blepharitis                                      Please mark the patients
         Chalazion                                                                                               Checked for Allergies
                                                          chosen Optometrist (tick as
         Conjunctivitis: allergic                         appropriate)
         Conjunctivitis: bacterial                                                                       Optometrist Signature ____________________________________________
         Conjunctivitis: seasonal and perennial                                                          Name Printed          ____________________________________________
                                                                   Alfred Jay Opticians                  Date                  ____________________________________________
         Corneal Abrasion                                          Ethics Eyecare
         Dry Eye                                                   Harley Bain Opticians
         Epiphora                                                  Ltd                                   Does the patient usually pay for prescription medications   YES / NO
         Ingrown Eyelash                                           Optitech Opticians
         Pingueculum                                               Angel Opticians
         Pterygium                                                 Vision Express                        Part 4: To be completed by the Patient
         Recurrent Erosion
         Red Eye*
*If a patient presents with red eye after 4.30pm that you do not consider can clinically wait until
                                                                                                         Signed                              Date
the next morning to be seen please refer to A&E                                                          Name

    Please state urgency of Appointment (GP to tick as Appropriate)
            Urgent Same Day appointment required                                                                            Please submit completed form to Enfield PCT
            Within 48 Hours
  Alison Mitchell-Hall                                      27                                    21/05/2011