Independent Optometrist, Loughborough, Leicestershire; Chairman, Leicestershire Local Optometric Committee Shared-Care Committee; Member, Charnwood & North West Leicestershire PCT Professional Executive Committee, Leicestershire, UK
Accepted date: August 2003
In December 2001 a general practitioner (GP) referral scheme was set up within the former North Charnwood Primary Care Group locality to improve the service to patients with ophthalmic problems. In the first year of the scheme,113 patients were referred to accredited optometrists by their GP. Of those, 84 (74%) were treated by the optometrists, 21 (19%) were referred tocasualty, and the other eight (7%) were referred on for specialist opinion. Audit revealed the project to be an unreserved success, especially amongst the patients. Referrals are examined locally, usually on the same day, thereby saving up to six months’ wait for a hospital appointment.
audit, ophthalmic problems, referrals
The ophthalmic co-management committee was set up as a subcommittee of North Charnwood Primary Care Group (PCG) in late 1999 for three reasons:
1 to tackle the unacceptably long ophthalmic waiting list in Leicestershire and particularly in Loughbor-ough
2even at that time, there were over 100 ophthalmic co-management schemes already in place throughout the UK (Association of Optometrists Primary Care Resource Pack)
3 the overwhelming advantages to GPs, ophthal-mologists, hospitals and especially patients.
Advantages to GPs
• Busy GPs have di¤culty in deciding whether to refer patients to hospital through lack of experi-ence, lack of instrumentation and time.
• There are 11 million GP consultations per year for ocular problems and optometrists have the equip-ment, training and time to investigate and treat ophthalmic conditions thereby freeing up GP surgery time.
Advantages to hospital and ophthalmologists
• Waiting times are reduced by the reduction of unnecessary appointments when optometrists monitor and triage patients in primary care.
• Quicker initial appointments result in more effect-ive treatment.
• When a patient is referred on to hospital by an optometrist, a detailed referral report ensures that the patient sees the most appropriate consultant.
• Ophthalmologists are relieved of managing minor problems leaving more time to treat more serious conditions.
Advantages to patients
• Patients are often seen the same day instead of having a six-month wait or longer for a non-urgent referral.
• Early treatment produces the optimal outcome.
• Local optometrists are invariably closer and more accessible.
• Parking is usually easier.
• Appointments are made at the convenience of patients rather than the hospital.
• Continuity of care is ensured, as the patient sees the same practitioner at each visit.
• The patient needs less time off work, possibly protecting the patient’s income.
• The consultation is conducted in a more relaxed atmosphere than the busy emergency or outpa-tient’s department.
The Patients Association produced a report in Feb-ruary 2002 following a survey of NHS ophthalmology services. One statistic showed that the average wait-ing time to see an ophthalmologist across the country was between three and six months, with 9% waiting over six months. The average waiting time to see an ophthalmologist for an urgent referral was 8–28 days with 3% waiting over 28 days. The author’s experience is that patients often wait over nine months for a simple procedure such as a posterior capsulotomy.
A survey to determine the enthusiasm for co-management was undertaken amongst all GPs in the former North Charnwood PCG in late 1999. Twenty-two replied out of 42. Individual comments on the questionnaires included:
‘It would be helpful if at times optometrists could refer directly to ophthalmologists rather than coming via the GP as the latter acts as a middle man, delaying things.’
‘Let’s finally move into the new millennium.’
‘Needs to be actively encouraged and pursued by the PCG.’
This response encouraged the author of this report to set up the GP Ophthalmic Referral Scheme in Decem-ber 2001.
Much experience had been gained by the Lough-borough Hospital Walk-in Centre Ophthalmic Refer-ral Scheme that was launched by the author in August 2000. This enables nurse practitioners to refer ophthalmic patients with inconclusive diagnoses to local accredited optometrists (for details of accred-itation, equipment and appointment timings see Appendix 1). Audited figures from that scheme indi-cate that 75% of patients are consistently managed by the optometrists, with the remainder referred on to either eye casualty or named ophthalmologists. Of course even those who are referred on benefit as they are accompanied by a detailed referral letter including such details as intra-ocular pressures, visual fields and retinal photography. A referral procedure protocol was developed together with referral form, report form, prescription fax form and patient satisfaction questionnaire (see Appendices 2–5).
The criteria for referral from GP to optometrist include the following:
• loss of vision including transient loss
• ocular pain
• systemic disease affecting the eye
• differential diagnosis of red eyes
• foreign body and emergency contact lens removal
• dry eye
• trichitic eye lashes
•differential diagnosis of lumps and bumps in the vicinity of the eye
• • ashes and • oaters.
More serious conditions such as retinal detachments and acute glaucoma naturally still require direct referral to hospital.
The procedure for referral is:
• a phone call is made to an accredited optometrist’s practice to request that the patient be seen and to agree a level of urgency
• if the patient presents within the times of agreed availability they are seen that day
• a referral form is completed by the GP, a copy is retained and the top copy is given to the patient in an envelope marked ‘confidential’
• the patient attends the optometrist at the appointed time and is examined.
Note that the referral form in Appendix 2 contains a space for the patient unique identification number. This is to satisfy Caldicott if the optometrist needs to fax the GP later for a drug prescription (see Appendix 4). After examining and treating the patient, the optometrist completes the report form detailing the results of the examination within five working days.
If medication is required the prescription form (see Appendix 4) is faxed to the GP to enable the patient to obtain a prescription (at present optometrists can only prescribe drugs privately – not through the NHS).
After the optometrist has examined the patient and completed the report form, a copy is sent back to the referring GP with a diagnosis and recommended treatment and whether a follow-up appointment has been arranged. The optometrist keeps a copy for his/ her own records. If a referral on to eye casualty or a named ophthalmologist is deemed necessary, then a further copy is given for the patient to present at the hospital. A special relationship has been arranged with the eye emergency department of a large local teaching hospital: if the optometrist feels the patient should be seen urgently then he/she telephones the eye emer-gency department and organises a convenient time for the patient to attend for examination. On occasion a specific course of investigation is decided over the telephone, e.g. the patient goes straight to the
• uoraescein angiography department instead of eye casualty.
In all cases, either on discharge from the optom-etrist or referral to hospital the patient receives a patient questionnaire (see Appendix 5) to complete. This is placed in a sealed envelope and forwarded to the strategy and development manager at the local primary care trust (PCT).
Table 1 is an analysis by incidence of the patients referred during the first year of the GP referral scheme.
Table 2 is an analysis by incidence of referrals by named condition presenting to the optometrist in the first year.
Table 3 compares the conditions referred to optometrists by GPs and the walk-in centre over the same period of time.
Several results are worthy of note:
• Anterior uveitis and potentially blocked nasal lacrimal system causing epiphora presented more commonly to GPs, presumably because they are usually more chronic problems that can wait several days for attention.
• Corneal abrasions, foreign bodies and subconjunc-tival haemorrhages are more acute problems and patients seek immediate advice by attending the walk-in centre.
• Posterior vitreous detachments are amongst the most common presentations to both the walk-in centre scheme and the GP scheme. The differential diagnosis of vitreous versus retinal detachment is crucial and the optometrists were pleased with the confidence that was placed in them to perform this.
• 74% of the 113 patients referred from GPs were dealt with by optometrists compared to 75% of the 111 patients referred by the walk-in centre in the same annual audit; these results were similar but with completely different patient mixes.
Although the optometrists were pleased with the level of referrals received during the first year of the scheme, analysis of the results revealed that although three of the local 13 GP practices each referred 20–30 patients, the remaining ten sent only six patients or less. It was resolved that visits to the latter surgeries are necessary to present the audit and discuss the success of the first year and thereby encourage the GPs to refer more eye problems to local accredited opto-metrists.
A pilot scheme is underway to reduce the ophthal-mic waiting list in the local hospital. Accredited optometrists are reviewing the referral letters and listing those patients who could potentially be man-aged by optometrists. Early analysis reveals that almost all of those listed have in fact been successfully managed and in a considerably shorter time than if they had remained on the waiting list.
Presentations have been requested and given to other PCTs and enquiries made from organisations in other parts of the country about expanding the scheme to their areas.
There are tremendous advantages in ophthalmic co-management and triage between GPs and optom-etrists. Everyone benefits: the GPs, the hospitals, ophthalmologists – but most of all the patients.
The author is indebted to the faith and foresight of the former North Charnwood PCG in providing the funds to set up and run the scheme and the readiness of the new Charnwood and North West Leicestershire PCT to continue that support.