RNIB Briefing for the Public Accounts Committee: inquiry into the management of follow-up outpatients across Wales

Attending from RNIB:

Ansley Workman, Director RNIB Cymru

Elin Edwards, External Affairs Manager RNIB Cymru

Gareth Davies, Stakeholder Engagement Lead for Eye Health and patient representative, RNIB

Background

In 2014, RNIB Cymru published “Real Patients, Real Harm”, a pivotal report which concluded that at least four people a month were losing their sight in Wales because of delayed and cancelled appointments. The report paved the way for a long overdue debate and subsequent major changes in Ophthalmology services in Wales.

The report found that the appointments system was at breaking point and unable to cope with demand, making a conservative estimate that 48 people a year were losing their sight because of delays in follow up appointments. 

An ageing population, new treatments and an increase in some underlying causes of sight loss, such as diabetes and obesity, have caused an increase in demand for ophthalmology appointments. Unlike other specialities, it should be noted that ophthalmology patients often enter the service for life as they will need reoccurring treatment.

RNIB Cymru raised concerns that NHS systems did not allow consultants to prioritise patients according to their clinical need. Hospitals were also failing to accurately record how many patients were losing their sight while waiting for an appointment. 

NHS Referral to Treatment Time (RTT) targets set by the Welsh Government has meant that priority is given to the patient’s first appointment which means that those who need follow up appointments and treatments often wait much longer than they should. In that time, without appropriate treatment, people’s sight can deteriorate rapidly. In ophthalmology the majority of patients at risk are follow up patients.

Most sight loss conditions are degenerative; however, many are also treatable, and in some cases blindness can be preventable. It is crucial therefore that people have timely access to eye care.

The current RTT target (26 weeks) is a risk as some patients require ongoing consistent review to achieve the best outcome. Clinical evidence suggests that 10% of new patients are at risk of harm compared to 90% of existing (formally known as “follow-up”) patients.

Developing the new measures

At the end of 2016, the Cabinet Secretary for Health tasked the Welsh Government’s Eye Health Care Steering Board with setting up a multi-disciplinary task and finish group, led by Dr Graham Shortland. RNIB took part in this group. The group was asked to establish new targets for both new and follow up appointments according to the patients’ risk of irreversible sight loss. Recommendations were made in June 2017 and two pilots were set up in Betsi Cadwaladr UHB and Abertawe Bro Morgannwg UHB.

The measures are compliant with relevant guidance, including NICE, Royal College of Ophthalmologists’ guidance, College of Optometrists’ guidance and the standards defined by the International Consortium for Health Outcomes Measurement, which aims to transform health care systems by measuring and reporting patient outcomes in a standardised way.

Three defined categories were agreed to support the clinical prioritisation and these are:

· R1: Risk of irreversible harm or significant patient adverse outcome if patient target date is missed

· R2: Risk of reversible harm or adverse outcome if patient target date is missed

· R3: No risk of significant harm or adverse outcome

The new performance measure is calculated as 95% of priority or risk 1 patients, to be seen by their target date or within 25% in excess of their target date for care/treatment.

Priority should be given to the new outcome measures to reduce avoidable sight loss. However, currently the new measures will work alongside RTTs.

The measures are currently being implemented nationally for all ophthalmic services (shadow reporting for all Health Boards began in September 2018) and follow the whole patient pathway through primary and secondary care. Health Boards will begin full reporting from April 2019.

The current situation

The recent Wales Audit Office report “Management of follow up outpatients across Wales” revealed that waiting times in Wales NHS are longer now than previous years (ophthalmology is second worst of all disciplines). 116,000 patients are waiting for an eye appointment; 28,000 patients waiting twice as long as they should be for an appointment.

Worryingly, in 2017/18, 100,816 ophthalmology appointments were cancelled or postponed in Wales, a rise of 5.5% on the figure two years before.

The demand for eye care services is outstripping Health Boards’ capacity to deliver a safe and effective service. People on hospital eye clinic waiting lists continue to tell us that their appointments are being cancelled at exceptionally short notice. Regular monitoring and treatment is essential to reducing the risk unnecessary sight loss. Delays to treatment can put people at risk of going permanently blind. In addition, delays can cause additional anxiety to a patient and much wider impact to the individual and additional services.

RNIB Cymru has welcomed the development of the new Outcome Focussed Measures for eye care and have worked with Welsh Government and partners to influence their development. The Measures have been devised to account for both new and existing patients, based on clinical need and risk of harm.

Wales is the first UK nation to introduce a performance measure of this kind for eye care patients and for that the Welsh Government should be congratulated.

However, it is important to state that the new measures in isolation will not create a safe and sustainable service. Without further resources and better use of resources, increased capacity and an up to date IT infrastructure (Electronic Patient Record or “EPR”) patients may still experience cancelled and delayed appointments.

Creating a safe and sustainable service

The development and introduction of the new Outcome Focused Measures are to be welcomed and RNIB Cymru is committed to working closely with Welsh Government and Health Boards (HBs) to support their implementation.

The problems relating to cancelled and delayed appointments however are deep-rooted and complex and must be addressed without delay by a system-wide approach which includes:

Systems

· The urgent implementation of an EPR. Eye clinics do not yet have the systems in place to deal efficiently with patients and allow for clinical prioritisation, in particular the lack of an EPR is often cited as a root challenge by clinicians. We understand that funds for an EPR have recently been signed off and we await details of roll out dates. However, we are concerned about the amount of time implementation may take.

RTT

· Prioritising the new Outcome Focussed Measures over RTTs. RTTs do not encourage clinical prioritisation. It will take time for the new Outcome Focussed Measures introduced by the Welsh Government in 2018 to become normal practise across HBs but a concerted effort is required by HBs to move over to the new system without delay.

Service redesign

· A major drive to redesign services. To date there has been a reluctance amongst some consultants to embrace service redesign and new models in primary and secondary care e.g. skilling up other professionals to undertake some elements of clinical care (prudent healthcare) or letting go of “follow up” patients to free up space for “new” patients.

· Better integration of community optometry and hospital eye services needs to be a priority. The move to primary care is slow and inconsistent. There are great examples of best practise, but this needs speed and consistency across the board. More work is now being delivered through ODTCs (Ophthalmic Diagnostic Treatment Centres) in the community, but there is still limited understanding and data on the impact ODTCs are having on sustainability. Better integration of community optometry and hospital eye services needs to be a priority and capital funding in place to resource ODTCs.

· Shared care barriers. Culturally we know there is often another barrier, in some HBs ophthalmologists can be reluctant for service to be redesigned between primary and secondary care.

Workforce planning

· A strategic, national and multidisciplinary approach to workforce planning. Workforce planning is not currently happening in a strategic enough way to ensure the correct professionals with the right level of skills are available to meet demand; training to top of license is not happening consistently or nationally. To deliver the government’s vision for eye care in Wales, we need to develop a pan-Wales eye care workforce plan that is clearly linked to capacity and demand data. Whilst some individual HBs are demonstrating good examples of workforce planning on a local scale, if we are to achieve service redesign and deliver additional capacity to meet current and future demand within the eye care system right across Wales, the pace of change must increase, and the work must be overseen by government at a national level.

· Shortage of consultants. There is a shortage of glaucoma consultants UK-wide including in Wales and more generally there is a shortage of eye care consultants. Understanding what this quantitative shortage is and its impact should be a consideration for this inquiry. 

Clinical pathways

· Consistent application of all-Wales clinical pathways.Currently All-Wales clinical pathways, for example for Cataracts, are not consistently applied and there is unacceptable variation across HBs in discharging to primary care.

Long term planning

· More robust forward planning by Health Boards. There is little evidence of HBs forward planning in terms of the long-term impact of recent changes and the impact on costs.

· Accountability. We agree with the findings of the Audit Office reports that accountability needs to be strengthened to ensure delivery of improvements to reducing follow up outpatient waiting lists.

· Serious incidents reporting. Where sight loss has occurred because of delays to treatment, HBs need to capture these as serious incidents. Reporting needs to be captured, questioned and analysed.  

Accessible Healthcare

· Health Boards must implement the Welsh Government’s Accessible Healthcare Standards. Across Wales, we know that Health Boards are not effectively implementing the government’s Accessible Healthcare Standards. To not routinely communicate with patients in a way that is appropriate to their needs is a patient safety risk.

Appendix

The stats

111,000 people live with sight loss in Wales.

Every day in Wales, nearly 4 people start to lose their sight and one in five people will live with sight loss in their lifetime.

The number of people with sight loss is predicted to increase by 32% by 2030 and double by 2050.

Eye health care services are some of the busiest in Wales with hospital ophthalmology clinics seeing 11% of all outpatient appointments.

End of document.

Contact: elin.edwards@rnib.org.uk