13 June 2018
In preparation for the National Tariff Consultation due to be released 14 June 2018, The Royal College of Ophthalmologists and patient organisations; Royal National Institute for the Blind (RNIB), International Glaucoma Association (IGA) and the Macular Society, have collaborated on key messages that will be used in response to the consultation. This group have written to NHS Improvement to make them aware of:
- The crisis in the hospital eye service is not news, it is overwhelmed due to the needs of an ageing population and the increase in chronic eye disease requiring long term treatment and follow up care
- How the current national tariff system adversely affects follow up patients, who are the most vulnerable group with long-term chronic eye disease
The key messages from The Royal College of Ophthalmologists and our partner patient organisations are outlined below and we encourage patients and medical and healthcare professionals working in the hospital eye services to respond to the upcoming National Tariff Consultation. The Royal College of Ophthalmologists encourages our members to either respond to the consultation or provide comments and feedbackto Laura Coveney, Policy Researcher, firstname.lastname@example.org
National Tariff – Key messages
Eye care services are under severe/unprecedented pressure
There has been a 20%-30% increase in clinical activity over the last 10 years so that now there are 9 million patients per annum attending hospital eye services with ophthalmology accounting for 8% of all outpatient appointments. A 30-40% increase in outpatient activity is predicted over the next 20 years. Demographic changes and treatments for previously untreatable conditions, including for long term conditions, have increased demand for services. There are not enough medical training posts to match this increased need so there are many unfilled consultant and SAS posts.
Despite every effort to innovate and improve efficiency services cannot cope with the number of patients
Ophthalmology is making every effort to improve in efficiency and manpower eg:
- Converting activity from in-patient theatre to outpatients, overnight stays to day cases, and general anaesthetic surgery to local anaesthetic surgery, with more productive theatre lists
- Increased use of the multidisciplinary team with orthoptists, optometrists and nurses working in extended roles delivering “medical” tasks and use of technicians and virtual clinics in hospitals.
- Increased use of community optometrists for reducing unnecessary referrals and managing low risk cases in the community
But currently there is still great difficulty in seeing the number of patients who need care.
Ophthalmology is not all planned operations and minor disease and there are enormous numbers of patients with chronic sight threatening disease
There is an assumption that ophthalmology is mainly cataracts and other planned operations or minor conditions. However, a significant proportion of ophthalmic patients have chronic diseases such as glaucoma, macular degeneration and diabetic retinopathy. These diseases cause loss of sight and blindness and, once the vision is lost, it cannot be regained.
Loss of sight is devastating and costly
Loss of sight, especially if avoidable, is devastating, reduces quality of life and independence, affects employment and the ability to drive, increases the risk or impact of numerous other health issues including falls, depression and dementia. This has a huge health and social care, and societal, cost.
The highest risk of visual loss is in follow up patients not new patients
The highest risk of permanent visual loss in ophthalmology is not in new patients – patients requiring follow up are 8-9 times more likely to have a chronic sight threatening condition.
Lack of capacity is causing permanent harm in follow up patients due to delays
There is strong evidence of the lack of capacity causing delays, particularly to follow up patients, with the highest risk of avoidable visual loss from delayed care being in chronic diseases (glaucoma, retinal conditions). Data from national incidents and research studies (British Ophthalmic Surveillance Unit) and from patient groups show about 200 patients per year with avoidable permanent vision loss since 2010. Many, many patients are becoming distressed and anxious about their delays.
The system is biased towards protecting new patients which increases the risk for the follow up patients missing care
Currently, the system is skewed towards favouring new patient activity over follow up, through: concentration on RTT18 targets for new patients and a lack of similar target for follow ups; no national data systems to collect outpatient delay data; commissioners efforts to drive down new to follow up ratios; and the front loading of the new patient tariff by 30% versus the follow up tariff. This is creating perverse incentives to see new patients in preference to follow ups and sends the message to providers and commissioners that follow ups are less important, which is worsening the situation already present due to inadequate capacity.
The patient experience
Research undertaken by the International Glaucoma Association (IGA) in 2017 shows that over 40% of their members have been adversely affected by cancellations or delays to follow up, with 22% of those experiencing delays saying that they were advised at the clinic they eventually attended that they had suffered further loss of their field of vision. This is leaving patients distressed, anxious and scared about the impact on their sight and their lives of the delays to their care. Only the confident and persistent are able to navigate through a dysfunctional system. Some people, who are able to afford it, refer themselves to private health care thus creating a two tier health system which is unacceptable and against the founding principles of the NHS.
Eye patients are very clear about the value of sight and the impact on their mental health and well being through needless loss of sight. A patient who works with The Royal College of Ophthalmologists, who has a potentially blinding eye condition and lung and breast cancer, says, ‘I would rather die from cancer with my sight intact than survive cancer blind. What shocks me is that I have to fight for everything to do with my eyes including medication, research into my eye condition and follow up appointments in a timely fashion to avoid continued loss of sight. However, with cancer, I am overloaded with appointments, information, support including acupuncture and counselling, medication and treatments and phone calls from various specialists, as well as approaches by researchers. Why can’t some of this money and service be diverted into my eye care?’
The All-Party Parliamentary Group (APPG) on Eye Health and Visual Impairment report, See the light: Improving capacity in NHS eye care in England, published in June 2018, confirms the scale of the issue and the harmful effect of delays on patients. For instance, of the 557 eye patients surveyed, just over half had at least one appointment or treatment delayed, 20% had at least one appointment or treatment cancelled and 15% reported both. For the majority of these patients this caused them anxiety, stress and had a negative impact on their day to day life. The report specifically concludes that the current national tariff for ophthalmology currently seriously disadvantages patients with glaucoma, wet age-related macular degeneration (AMD) and diabetic retinopathy who require follow up appointments and are particularly at risk of avoidable sight loss and calls for this to be urgently reviewed (recommendation 6). It also makes many other important recommendations including mandated measurement of and targets for follow up timing adherence, a higher national priority for eye care, better overall funding and staffing, and support for local and regional strategic service redesign and transformation.
Many ophthalmology disorders like glaucoma and age-related macular degeneration are lifelong serious conditions and patients should be treated equitably and feel supported and cared for throughout life and not just at the point of diagnosis.
The Royal College of Ophthalmologists, the RNIB, IGA and the Macular Society are calling for:
- A reversal of the tariff front loading structure back to 10%
- Tariffs for non face to face and non consultant care
- Avoidance of block contracts
- The recommendations of the APPG report addressed at all relevant levels from the Department of Health to achieve adequately funded, staffed, organised and monitored services for ophthalmic conditions for current and future demand to protect patients
References and further reading
APPG report on eye health capacity & demand ‘See the Light’ https://www.rnib.org.uk/professionals/health-professionals/appg-eye-capacity
RNIB. Sight loss: A public health priority. (2013). at http://www.rnib.org.uk/services-we-offer-advice-professionals-health-professionals/public-health-professionals
IGA Eye Health Services Failing People with Glaucoma https://www.glaucoma-association.com/news/eye-health-services-failing-people-glaucoma/
Surveillance of sight loss due to delay in ophthalmic treatment or review: frequency, cause and outcome. Foot B, MacEwen CJ. Eye (2017) 31, 771–775 https://www.rcophth.ac.uk/2017/02/bosu-report-shows-patients-coming-to-harm-due-to-delays-in-treatment-and-follow-up-appointments/
NSPA patient safety alert: rapid response alert on glaucoma 2009
Davies A, Baldwin A, Hingorani M, Dwyer A, Flanagan D. A review of 145234 ophthalmic patient episodes lost to follow-up. Eye 2017; 31: 422–429.
Pezzullo L, Streatfield J, Simkiss P, Shickle D. The economic impact of sight loss and blindness in the UK adult population. RNIB and Deloitte Access Economics 2016