Agenda item 7 Date 2/2/2012

Transcription

1 Agenda item 7 Date 2/2/2012 BUSINESS CASE FOR COMMUNITY OPHTHALMOLOGY SERVICE FOR EAST AND NORTH HERTS CCG Decision Discussion Information Follow up from last meeting Report author: Dr Rachel Joyce Report signed off by: Rachel Joyce Purpose of the paper: To seek Board approval for the proposed Business Case Recommendations to the Board: 1. To agree the proposed Business Case 1

2 BUSINESS CASE FOR COMMUNITY OPHTHALMOLOGY SERVICE FOR EAST AND NORTH HERTS CCG 1. Executive Summary This business case is based on work carried out in West Herts, which included a service review of Hospital Eye and Community Ophthalmology services. The majority of patients with possible Ocular Hypertension (OHT)/ Glaucoma can be completely managed in the community assessment and treatment (CATs) services, with very limited need for onward referral. All OHT/ glaucoma cases could/ should be triaged by a CATs service, with most subsequently managed by CATs. Consultants should provide clinical decision making on each case that is seen in the community service; to improve confidence in the services and to avoid unnecessary follow ups. Skill mix can still be used eg for ophthalmology tests before consultant review to optimize efficiency of the services. Service specifications would need to reflect this. In line with the previous two recommendations, a community service should be procured for East and North Herts area. Approximately 20% or more of ophthalmology consultations can be held in community, which at a 20% or more saving on tariff would result in significant cost savings, estimated to be approximately 316,400 total savings per annum. 2. Background This business case is based on work carried out in West Herts, which included a service review of Hospital Eye and Community Ophthalmology services. The principles and potential benefits however are no different for East and North Herts ophthalmology services, so this business case is an adaptation of work that has been approved for Herts Valleys CCG. West Herts Hospitals Trust have for some time struggled to deal with the rising demand for ophthalmology outpatient appointments. Much of this increase in demand is due to an aging population, a rise in the prevalence of long term conditions such as diabetes, and also new treatments and technologies that mean many eye conditions are more amenable to treatments either medical or surgical. At the same time, the clinical commissioners and PCT were also recognising the need for service redesign to ensure value for money in a specialty with such a large volume of activity. 2

3 3. Audits 3.1 West Herts Hospitals Acute Trust The Trust requested a capacity review, and the first step was an audit at the Trust to ascertain potential for service redesign. The audit identified that approximately 20% of acute referrals could have been avoided the largest proportion being ocular hypertension/glaucoma. [Of interest to both CCGs, but not relevant to this business case, the audit identified immediate cost savings for the urgent eye clinic which has taken place (a re-categorisation of the attendances as A&E attendances).further service redesign opportunities were also identified in Paediatric Ophthalmology (possibly saving up to 50% of acute referrals) this is a separate piece of work, and is not covered here. It was also found that a large number of cataract referrals did not meet surgical threshold criteria, leading to unnecessary consultations, which has been addressed by referral triage which is on track for 200K savings.] 3.2 Ophthalmology Community Assessment and Treatment Services (CATs) There was uncertainty about the cost effectiveness of the community services in West Herts in terms of where they should sit within the ophthalmology pathways, in terms of follow ups, and referrals on to the Hospital Eye Services, as well as the seniority and experience of the clinicians involved. To clarify the position, two further audits were conducted at DLH and The Practice. All three audits were conducted by public health with consultant ophthalmology input Findings of Audit at The Practice A random sample of 40 consultations, two different months Most came via optometrist New cases seen were appropriate Many follow ups could be avoided often due to junior staff uncertainty or lack of testing availability Managed most in house only 2 resulted in onward referral to HES (there was one case where it was judged that an onward referral should have been made but was not). 3

4 The paper triage system was working well, and the Practice were appropriately triaging out cataracts, as they could not book them directly for surgery (so avoiding a second consultation). It was noted they were not seeking prior approval for minor operations, and this has been rectified. The vast majority of the workload was related to ocular hypertension and glaucoma. 4

5 In conclusion, in terms of cost-effectiveness, there was no issue with onward referral, and they were appropriately paper triaging cataracts to the Hospital Eye Service. To address the unnecessary follow up consultations, it was agreed that the issue of access to tests needed to be investigated which as has now been resolved. It was also agreed that there needed to be consultant input into the management of all patients to avoid unnecessary follow ups. Anecdotal feedback from some GPs supports this move as some report they would refer more patients to the Practice instead of acute Trusts if consultants were more involved in case decision making. One possible way of managing this efficiently would be to involve junior staff/ skill mix in testing, with consultant decision making on test results Findings of Audit at DLH This was a very different service to that run at the Practice, particularly as it is consultant run. The casemix is however very similar. Key findings were: A random sample of 40 consultations from November 2010 were considered Most also optometrist generated referrals Similar case mix mostly OHT/ glaucoma Paper triage issues resulted in some unnecessary activity, but referrals were appropriate Follow ups not a problem Managing most cases in house, except those that should have been paper triaged to HES in first instance. Record keeping needs improvement has been addressed 5

6 Maculopathy OHT/Glucoma Cataract Diplopia, Diabetic Retinopathy, Thyroid Eye Disease Aniscoria Number of Cases Wet Macular Degeneration Vitreous Detachment Dry Eyes Macular Degeneration cases resulted in onward referral to Acute, 6 of which should have been picked up at triage mostly cataracts, and also diplopia. This issue has been addressed. Otherwise the service was able to manage most cases appropriately, with only one possibly unnecessary follow up. The conclusions were that the PCT needed to enforce existing contract requirements regarding triaging conditions/ straight to Acute. Prior approval of cataract referrals has since addressed this issue. Unnecessary follow ups were avoided because of the seniority of staff, but more skill mix for testing (with consultant decision making on each patient) could improve efficiency of the service. 3.3 Overall conclusions from all audits in terms of cost-effective service redesign related to CATs suitable case mix. The majority of patients (with agreed red flags if necessary) with possible OHT/ Glaucoma are can be totally managed in the CATs services, with very limited need for onward referral. All OHT/ glaucoma cases could/ should be triaged by a CATs service. Consultants should provide clinical decision making on each case seen in the CATs to improve confidence in the services and to avoid unnecessary follow ups, but skill mix for testing may optimize efficiency of the services. Service specifications will need to reflect this. In line with the previous two recommendations, a CATs service should be procured for East and North Herts, ideally with all OHT/ glaucoma referrals going to the CATs in the first instance. 6

7 4. Data analysis activity and costs Data for the West Herts locality populations was analysed hospital outpatient activity and also activity at both DLH and The Practice. The following table shows the proportion of activity that is being managed in the CATs. This appears to be in line with the findings that 20% of acute activity could be managed in the community services. % CATs NP % CATs FU % CATs total DacCom PBC Limited % Hertsmere Commissioning % Red House Practice % St Albans & Harpenden % WatCom PBC Limited % The next table shows the current activity and costs for outpatient ophthalmology by locality. Ophthalmology outpatient attendances East and North Herts CCG patients November 2010 to October st Attendance Follow Up Atts Total No Total Cost Locality No Cost No Cost East , , ,543 North , , ,646 North Herts , , ,153,926 South , , ,218 Stevenage , , ,036 Welwyn Hatfield , , ,094 West & Central , , ,144 Grand Total ,094, ,431, ,525,607 7

8 5. Potential Cost Savings On the basis of the above tables, if a consultant led CAT service/s is commissioned for all localities, with all suspected glaucoma/ OHT being triaged through the service, approximately 25-34% of new consultations could take place in the CATs service, and approximately 8-14% of follow ups. The table below calculates overall costs by locality if the same number of patients were seen but 30% of new patient consultations were in Community, 10% of follow ups were seen in Community, and Community charged 20% less than tariff (versus tariff plus MFF). If this is compared to the current total costs, then that would result in savings in East and North Herts of at least 316,400 per annum. This is likely to be a conservative estimate, as further savings may be possible for instance discharging existing follow up glaucoma/ OHT patients to a CATs service. Cost acute new patient consultations Cost acute follow ups Cost community new patients Cost community follow ups Total cost Total savings East 128, ,887 38,116 20, ,752 31,791 North 90, ,085 27,444 15, ,749 19,898 North Herts 299, ,860 89,725 48,698 1,091,252 62,674 South 160, ,355 45,481 26, ,472 41,746 Stevenage 232, ,594 69,189 34, ,555 46,482 Welwyn Hatfield 302, ,978 89,457 36, ,791 58,303 West & Central 251, ,520 74,700 37, ,637 55,507 Total 1,465,930 3,088, , ,886 5,209, ,400 Queries to: Dr Rachel Joyce Consultant in Public Health Medicine NHS Hertfordshire rachel.joyce@hertfordshire.nhs.uk 8