SCHEDULE 3 SERVICE SPECIFICATION ACCESS TO CATARACT SURGERY

SCHEDULE 3 SERVICE SPECIFICATION ACCESS TO CATARACT SURGERY 1 SERVICE AIMS 1.1 A cataract is an opacification (clouding) of the eye s natural lens. It usually develops over a period of time causing a gradual deterioration in eyesight and may eventually lead to blindness (NICE 2007). 1.2 The most effective treatment is surgical removal of a cloudy lens using an extra-capsular or intra capsular technique. In both cases the affected lens is removed and replaced with a plastic lens (an intraocular lens implant) which stays in the eye permanently. Cataract operations are performed using a local anaesthetic and patients allowed home the same day. 1.3 The service aims to improve health and reduce inequalities by providing appropriate access to cataract surgery according to a local pathway. This pathway may change from time to time in line with based on evidence based policies and / or national directives 1.4 The service is expected to reduce the number of unnecessary referrals from primary care to secondary care, supported by the provision of more accurate referral information. 1.5 The service aims to promote fairness across Northamptonshire, ensuring that the most severely affected patients get the opportunity of surgery in a first eye before second eye surgery is offered to others. 1.6 The knowledge and skills of community ophthalmic practitioners will be better utilised. 2 SERVICE OUTLINE 2.1 The service provides for the assessment and direct referral of patients to secondary care for cataract surgery. 2.2 The service is provided by local ophthalmic practitioners who have a range of equipment to facilitate detailed examination of the eye, as well as the specialist knowledge and skill. 2.3 The service is accessed by patients direct from the local ophthalmic practitioner, either by: self-referral to the service via local signposting ("self-referral") attending a GP who recommends assessment by an optometrist ("GP referral") 1

referral from an optometrist who does not hold a contract for Access to Cataract Surgery ( optometrist referral ) 2.4 The service is available to all persons registered with a GP practice located within the geographical area of the PCT. 3 SERVICE PROVISION 3.1 The service shall be provided during the hours detailed in Part 3 of Schedule 1. 3.2 Referrals to the service shall be made in accordance with paragraph 4.9 of this Schedule 3. 4 SERVICE SPECIFICATION & CRITERIA 4.1 Service to be commissioned 4.1.1 This service provides for the assessment and referral of patients for cataract surgery according to their corrected visual acuity. 4.1.2 The Contractor shall identify patients whose cataract is at a suitable stage for surgery according to the criteria for referral set out in clause 4.3. 4.1.3 The Contractor shall ensure that patients meet the criteria as set in the PCT s Commissioning Policy for Access to Cataract Surgery 4.1.4 The Contractor shall ensure patients that meet the criteria are offered choice of provider for surgery and the referral is sent directly to the Provider. 4.1.5 The Contractor shall ensure that all patients suitable for surgery (and all their carers and support staff where appropriate) receive appropriate information on their condition and on cataract surgery. 4.1.6 In all cases where the access criteria are met, prior to initiating a referral for possible cataract surgery, the optometrist shall discuss with the patients the potential benefits and risks of cataract surgery and have obtained an assurance that the patient would accept cataract surgery if offered. 4.1.7 The Contractor shall forward a copy of the referral to the patient s GP with a request that the medical history of the patient is forwarded to the relevant Provider. 4.2 Criteria for referral 2

4.2.1 Cataract first eye The patient will have a corrected visual acuity of 6/12 in the worst eye. 4.2.2 Cataract surgery for second eye Where the cataract procedure on the first eye has achieved a VA of 6/9 or better, and the VA for the second eye is 6/24 or better, then the patient should be discharged, unless receiving treatment for any other eye condition. The patient should be advised to attend an optometrist for sights test annually or earlier if they notice any deterioration of vision. If the first eye does not achieve a visual acuity of 6/9 or better after surgery then the second eye should be dealt with on clinical merit, taking into account any directly related work circumstances, i.e. the requirement for night driving. There are circumstances where, despite good acuities, there may still be a clinical need to operate on the second eye fairly speedily, e.g. where there is a resultant anisometropia (a large refractive difference between the two eyes) which would result in poor binocular vision or even diplopia. In these circumstances the notes should clearly record this, so that it can be identified during any future clinical audit. Refer to the PCT s Commissioning Policy for Access to Cataract Surgery for criteria. 4.3 Patients who do not meet the criteria 4.3.1 All patients with corrected vision better than 6/12 where cataract surgery is indicated will need to be referred to the prior approval team at NHS Northamptonshire. 4.4 Prior Approval Process 4.4.1 Referrals for cataract surgery which fall outside of the criteria in 4.3 should be sent to the Prior Approval Team at NHS Northamptonshire using the appropriate Individual Funding Request (IFR) form. 4.4.2 The following factors will be taken into consideration by the Prior Approval Team:- a) Patients who are still working in an occupation in which good acuity is essential to their ability to work, (e.g. watchmaker) b) Patients with subcapsular or cortical cataracts who experience problems with glare and a reduction in acuity in bright conditions c) For driving: 3

Patients who need to drive and who experience significant glare which affects driving Patients who, for occupational reasons need to drive at night and who experience glare which is attributable to their cataract(s) Patients with visual fields which are borderline for driving, in whom cataract extraction would be expected to significantly improve their visual field d) Patients with glaucoma (especially angle closure) who require cataract surgery to control their intraocular pressure e) Patients with diabetes who require clear views of their retina to screen for retinopathy 4.4.3 If surgery is conducted for associated ocular co-morbidities, then the clinician responsible for the patients shall inform the Prior Approval Team about this procedure after surgery has been done. 4.5 Monitoring and Follow Up 4.5.1 Where the cataract procedure on the first eye has achieved a visual acuity of 6/9 or better and the visual acuity for the second eye is 6/24 or better then the patient should be discharged unless receiving treatment for any other eye condition. 4.5.2 Patients who do not meet the criteria for cataract referral should be advised to attend an optometrist for sight tests annually or earlier if they notice any deterioration of vision. 4.6 Equipment 4.6.1 The Contractor shall have adequate and appropriate equipment available to undertake this service, including a slit lamp, bio microscope and fax machine. 4.6.2 The Contractor is responsible for ensuring that all the required equipment is available, operational and well maintained. 4.7 Accreditation 4.7.1 The Contractor and all ophthalmic practitioners employed or engaged by the Contractor in the provision of this service shall have undertaken appropriate training based on modern authoritative clinical opinion. 4.7.2 The Contractor shall ensure that all practitioners are compliant with the practice protocols for the clinical management of all patients in receipt of this service. These protocols must be in line with best practice clinical guidelines and reviewed at least every 12 months. 4

4.7.3 The Contractor shall be responsible for ensuring that all persons employed or engaged by the Contractor in respect of the provision of the services under the Contract are aware of the administrative requirements of the service. 4.7.4 The PCT will provide GPs and optometric practices with a regularly updated list of contractors providing this service. 4.8 Patient Eligibility 4.8.1 The service is available to all persons registered with a GP practice located within the geographical area of the PCT. 4.8.2 If a patient wishes to communicate using a language other than English, the Contractor shall have access to the interpretation and translation service available through the PCT. 4.9 Referral and Patient Pathway 4.9.1 Patients shall attend the Contractor at the practice premises for dilated examination (where clinically appropriate) and cataract diagnosis. 4.9.2 If the patient meets the referral criteria and wishes to proceed to surgery the Contractor shall complete a cataract referral form and offer the patient the choice of provider from the Choosing Your Hospital leaflet. 4.9.3 The Contractor shall send the referral form to the chosen provider either by secure e-mail or fax. 4.9.4 The Contractor shall send a copy of the referral to the patient s GP which will generate the request for a medical summary to be sent to the chosen provider. 4.9.5 The Contractor shall send a further copy of the referral to the PCT which will generate the payment to the Contractor. 4.9.6 Following surgery the secondary care provider will complete a Cataract Post operative Review Form and send it to the Contractor. 4.9.7 The Contractor shall carry out a post operative review and fax the review form to the PCT on the number provided to claim the Post Operative Follow Up fee. 4.9.8 A flowchart of the patient pathway is attached as Appendix 1. 4.10 Record Keeping and Data Collection 5

4.10.1 The Contractor shall maintain appropriate clinical records to show:- 4.11 Service Review The results of the dilated examination and the clinical diagnosis Whether or not the patient meets the referral criteria Details of any referral made Details of associated ocular co-morbidities or other reasons for referral Details of any post-operative review and/or follow-up required 4.11.1 The Contractor shall co-operate with the PCT as reasonably required in respect of the monitoring and assessment of the services, including:- Answering any questions reasonably put to the Contractor by the PCT Providing any information reasonably required by the PCT including clinical audits, distribution of patient satisfaction surveys as developed by NHS Northamptonshire and release of non-identifiable patient information for the purposes of quality improvement initiatives to be undertaken by NHS Northamptonshire relating to this specific patient group. Attending any meeting or ensuring that an appropriate representative of the Contractor attends any meeting (if held at a reasonably accessible place and at a reasonable hour, and due notice has been given), if the Contractor s presence at the meeting is reasonably required by the PCT 5 CLINICAL GOVERNANCE 5.1 The Contractor is required to achieve Level One of the Quality in Optometry Scheme. 5.2 Infection Control 5.2.1 In addition to the requirements of clause 28, the Contractor shall specifically ensure that:- The clinical environment is maintained appropriately to reduce the risk of healthcare acquired infections Waste is disposed of safely without risk of contamination or injury and is in accordance with national legislation and regulations Clinical equipment is managed appropriately to reduce the risk of healthcare acquired infections 6

Hand washing is undertaking correctly using an appropriate cleansing agent. Hand washing facilities shall be adequate to ensure hand hygiene can be carried out effectively The environment is cleaned to an appropriate standard and monitored regularly Items in direct contact with the eye shall be disposable and shall not be re-used* *re usable tonometer heads may be used as an exception providing the correct disinfection procedures have been carried out 5.3 Facilities and Equipment 5.3.1 In addition to the requirements of clause 25, the Contractor shall meet the following non-exhaustive list of requirements:- 5.4 Serious Incidents Hand washing with hot/cold water to be available in the consulting room Liquid soap Alcohol gel Paper towels Single use items Clinical waste collection Sharps containers Washable work surfaces Floor and wall surfaces maintained in a clean and hygienic manner Cleanable lighting, especially lighting close to the patient 5.4.1 In addition to the requirements of clause 66, the Contractor shall comply with the requirements of the PCT s Policy for the Reporting and Handling of Serious Incidents. 5.4.2 Fitness to practice concerns shall be reported by the Contractor to the PCT Professional Lead - Optometry and will be investigated by the PCT. 5.5 Clinical Audit 6 PAYMENT 5.5.1 The Contractor shall participate in any clinical audit activity as reasonably required by the PCT, and maintain appropriate records to evidence and support such activity, including a spreadsheet or table showing the outcome of each clinical audit. 7

6.1 Payment for the service is on a cost per case arrangement. The PCT shall pay the Contractor 44.00 for each initial pre-operative assessment and referral as outlined in this Schedule 3 and 20.00 for each Post Operative follow-up. 6.2 Payment will be made to the Contractor on a quarterly basis via BACS. 6.3 The faxed referral to the Patient Care Advisers will trigger the payment. 6.4 NHS Northamptonshire may audit the claims from time to time. 8

7 PARTICIPATING ACCREDITED OPTOMETRISTS The ophthalmic practitioners named below have successfully undertaken accreditation and will provide the acute community eye care service for patients presenting at the practice premises. The ophthalmic practitioners named below declare that they have read and understood this service specification. The Contractor shall ensure that any additional ophthalmic practitioners who are to provide the acute community eye care service for patients presenting at the practice premises, have successfully undertaken accreditation, have read and understood this service specification, and have signed a copy of this service specification, which the Contractor shall provide to the PCT. 9