OPHTHALMIC PRIMARY CARE

What is Ophthalmic Primary Care? Formulating a succinct and workable definition of ophthalmic primary care (OPC) or primary care ophthalmology has proved challenging. The traditional nomenclature of primary, secondary and tertiary care is based mainly on the environment in which healthcare interventions take place (general practice or community care, district hospitals and regional centres respectively), but also to some extent reflects a hierarchy of specialisation. In some medical disciplines (eg paediatrics, dermatology), it might be possible to define the boundary between primary and secondary care in terms of a range of clinical conditions which any competent general practitioner should be able to manage. It is unsatisfactory to attempt to define OPC in terms of a range of eye conditions which could routinely be managed in general practice or community optometric practice, because the experience and expertise of individual general practitioners and optometrists varies widely. This would constrain the definition of OPC to a limited range of eye conditions. A better approach is to define OPC in terms of the characteristics and outcome of the consultation. Riad et al1 have proposed the following comprehensive definition: the provision of first contact care for all ophthalmic conditions and the follow-up, preventive and rehabilitative care of selected ophthalmic conditions. It can be delivered in a variety of settings and by a diverse workforce, but in strict, efficient and timely coordination, to attain the best clinical outcome possible for the patient. A service is designated as ophthalmic primary care, only if appropriately integrated with the patients main primary care provider, in order to ensure continuity, longitudinality and comprehensiveness in the overall care of the patient. The primary care ophthalmic service itself should be accessible, equitable, knowledgeable, responsive and efficient. In these aims, it is supported by the population sciences which identify the medical and service needs of the population served. This definition permits considerable local variation in OPC provision in terms of the setting in which it occurs and the skill-mix of the workforce, but it includes a number of characteristics which should be at the core of every OPC service: It requires the participation of ophthalmologists and close links with the hospital eye service if it is to provide ..first contact care for all ophthalmic conditions.. It must be geared to the needs of the population as well as to the needs of the individual if it is to be accessible, knowledgeable,

responsive and efficient. This implies close links with general practice and community optometric practice. It requires good leadership and reliable channels of communication if it is to be delivered in a variety of settings and by a diverse workforce. Without this, there is considerable danger of lapses in continuity of care or wasteful duplication of effort.

Who is providing Ophthalmic Primary Care currently? The Hospital Eye Service (HES). Most hospital eye departments provide a clinical service via outpatient clinics and ophthalmic accident & emergency (or urgent referral) clinics which can be said to offer first contact care for all ophthalmic conditions. Indeed, most departments are able to offer a complete package of care for most eye conditions. However, the accessibility of the HES varies with geographic location and its responsiveness is often limited by a constant struggle to keep pace with increasing demand. The HES has a multi-professional workforce and many units make good use of this variety of professional skills in providing OPC. However, OPC provision within the HES tends to be based on retrospective assessments of demand rather than on prospective assessments of the needs of the population being served. General Practitioners. Most GPs have had very little exposure to clinical ophthalmology at undergraduate level or in GP vocational training programmes. The OPC service they provide may well be accessible and responsive but is likely to be very limited in scope. A small number of GPs have undergone additional training in ophthalmology and provide a more comprehensive OPC service in general practice. Ophthalmic Medical Practitioners. There are believed to be about 660 OMPs in active practice in the UK, probably equating to about 250 whole time equivalents. Department of Health workforce statistics2 and a recent national survey of OMPs3 suggests that their numbers are in decline and are likely to decline further because of impending retirements. OMPs normally possess a postgraduate qualification in ophthalmology and, working together with community optometrists, are often able to provide to provide a service which is accessible, knowledgeable, responsive and efficient. However, the General Ophthalmic Services (GOS) contract does not allow OMPs to issue NHS prescriptions for drugs which limits their ability to provide first contact care for all eye conditions. Optometrists. There are about 7000 registered optometrists in the UK, the majority of whom work in community optometric practice. Most optometric practices are equipped with slit lamps, tonometers and automated perimeters. After graduating, trainee optometrists must work for a year under supervision in a training practice or hospital eye department before achieving full registration. During the pre2

registration year, trainees must attend a number of hospital eye clinics as observers. Since 1968, registered optometrists have been allowed to sign written orders (effectively, private prescriptions) for a limited number of ophthalmic medications. Legislation is soon to be enacted which will permit supplementary prescribing and later, independent prescribing by optometrists. Most community optometric practices are situated in easily accessible locations, and it is usually possible to obtain appointments at short notice. The scope of OPC in community optometric practice is heavily dependent on the experience of individual optometrists and the regularity with which they encounter eye disease. In some areas of Britain, primary care trusts (PCTs) have funded schemes whereby community optometrists who have undergone additional training receive referrals or self-referrals of patients who might otherwise present to the GP or the local ophthalmic A&E service. The effect of these schemes on demand for ophthalmic consultations in general practice and on demand on the HES has not yet been fully evaluated. Orthoptists. There are about 900 registered orthoptists in the UK. Their specialist skills in the assessment of vision in children and ocular motility disorders in all age groups support OPC within the HES and outside. Many orthoptists undertake clinical tasks beyond their core skills. Nurses. In many hospital ophthalmic A&E or primary care clinics, specialist nurses triage, treat and discharge patients in accordance with agreed protocols.

Designing an Ophthalmic Primary Care Service There are many examples of clinical services in the UK which could be said to possess most, if not all of the characteristics of OPC as defined by Riad et al1. Some are entirely hospital-based, whereas others are largely communitybased but with close links to the HES. Some cover large areas, while others are limited to a small locality. Most have evolved in response to local need, often through the hard work of small numbers of committed individuals. It is neither necessary nor desirable to impose a single blueprint for an ideal OPC service, but there are a number of questions which should be considered when designing, or evaluating a proposal for an OPC service: Does the design of the service genuinely reflect the needs of the population it is intended to serve in terms of accessibility and comprehensiveness? The needs of a large metropolis may be quite different from the needs of a scattered rural population and this may determine whether a service is relatively centralised or relatively devolved.

Does the service maintain close links with hospital specialist services, with local general practices and with relevant community services (optometry, community orthoptic service, social services etc)? Does the OPC service have adequate capacity to offer appointments within an appropriate time frame to its target population, or is the local ophthalmic accident and emergency service acting as an overflow for excess demand? Does the service simplify the referral process and the patient journey so that the point of diagnosis and initial management of the patients eye problem is reached with a minimum of intermediate steps? Do those who refer into the service know how to use the service appropriately and when to by-pass it? Does the service have any obvious vulnerabilities (for instance, does its viability depend excessively on one key individual?) Does the service provide (or facilitate access to) in-service training and continuing professional development for all staff? Members of all professional groups (ophthalmologists included) are vulnerable to attrition of knowledge and skills when working in isolated practice. Does the service have adequate provision for clinical record keeping and the reliable and secure transfer of clinical information between providers of care? Are the costs of the service transparent? Is there a framework for meaningful clinical audit in place?

What should be the role of ophthalmologists in Ophthalmic Primary Care? Taking the working definition of OPC as proposed by Riad et al1, there are a number of implications for the future role of ophthalmologists in its provision: 1. Ophthalmic Primary Care requires an epidemiological perspective. The launch of the government-led initiatives Action on Cataract (2000) and The National Eye Care Plan (2004) and the National Service Framework for Diabetes have put eye disease on the map as a public health issue, arguably for the first time since eye hospitals were established in response to an epidemic of Egyptian Ophthalmia (trachoma) imported by soldiers returning from the Napoleonic wars. These initiatives may be imperfectly executed and incompletely funded, but the fact that cataract, glaucoma, age related maculopathy , low vision and diabetic retinopathy are being considered on a national rather than a local basis is significant. 4

OPC covers a wide range of diagnostic entities, but with the unifying characteristic of providing first contact care. It is already provided in a variety of settings and by a diverse workforce, but almost always in a reactive manner (ie in response to historical levels of demand, waiting time targets, and local perceptions of what patients or GPs want). The inevitable results are chronic under-capacity, and inefficient use of the capacity which exists. This in turn makes it extremely difficult to predict the effect of local interventions to increase capacity, such as waiting list initiatives, additional urgent referral clinics or referral refinement schemes. What is required is a concerted attempt to estimate population need, taking account of local variations in age distribution, ethnic mix and levels of social deprivation. By implication, there is a need for more ophthalmologists with skills in ophthalmic epidemiology. 2. Ophthalmic Primary Care needs ophthalmologists The potential for optometrists, GPs with a specialist interest, orthoptists and nurses to contribute to OPC has rightly been emphasised. Each of these professional groups can bring to OPC particular skills and particular perspectives. Of these professions, optometry has the greatest numerical strength by a considerable margin. However, (without in any way disparaging the contributions of other professions) OPC can only provide first contact care for all ophthalmic conditions with the active participation of ophthalmologists. Ophthalmologists have a crucial role in OPC, not just as providers, but as trainers, assessors and service coordinators. Primary care ophthalmologists will need to maintain very close working links with general practice, community optometrists, primary care trusts and hospital eye departments if OPC is truly to be based on the needs of the population it serves. A successful OPC service should be designed to minimise the number of steps in the patient journey whatever the level of complexity of the clinical condition. 3. Ophthalmic Primary Care needs to become a sub-specialty of ophthalmology in its own right Ophthalmologists who choose to specialise in OPC will need a wide range of skills not all of which can be easily acquired in ophthalmology specialty training as it is currently structured. They will need to have experience in epidemiology, medical teaching and assessment and health service management, but they will not necessarily need to perform ophthalmic surgery. Leaders and innovators in this field will not be failed surgeons, but are more likely to be established ophthalmologists who may have held senior educational or managerial positions previously and who wish to enter a new phase of their career. This group will probably also include senior Staff and Associate Specialist ophthalmologists and GP ophthalmologists who are already

leading successful local OPC services. The next logical step is to create a training programme for the next generation of primary care ophthalmologists. The training curriculum would have a certain degree of overlap with surgical ophthalmology but would diverge significantly after perhaps the first year of specialist training. It would be desirable to have a separate Certificate of Completion of Training in OPC. It would be possible to construct a less comprehensive, but related training programme to accommodate GPs who wish to develop an interest in ophthalmology but to continue to work in general practice. 4. Local initiatives will shape national policy OPC will probably not develop as a sub-specialty of ophthalmology in a top-down fashion. It will have to justify a dedicated training programme and a specialist qualification. There are already a number of successful OPC services in existence. Some are subspecialty services within hospital eye departments. Some are outreach services from hospital eye departments. Some are based in general practice. As ophthalmologists with an interest in OPC share their experiences, it is likely that models of service provision which have proved successful and cost effective will be copied and adopted in other areas with similar catchment populations.

If not primary, secondary and tertiary care, then what? The traditional nomenclature of primary, secondary and tertiary care is not helpful to an understanding of how ophthalmology services might be provided in the future. The appendix to this chapter is a suggested scheme consisting of six tiers of service. The tiers are not rigidly tied to particular working environments, but they describe the types of clinical activity which might take place and the professional groups which might be involved. The model does not imply that a patient whose clinical condition is destined for a particular tier of the service needs to be triaged at every intermediate tier on the way. For instance, a patient presenting to optometry with suspected choroidal neovascularisation (level 1 or 2) needs to go directly to level 5, bypassing levels 3 and 4 to avoid unnecessary delay.

Acknowledgements: The ophthalmic primary care subcommittee produced two discussion papers (The Future of Ophthalmic Primary Care4 and Ophthalmic Primary Care as a Career5) which were circulated widely for comment. This article is a distillation of the discussion papers and the constructive feedback they generated. We particularly wish to thank Miss Rosalind Harrison, Mrs Manijeh Wishart, Mr John Keast-Butler, Mr Frank Munro, Mr Trevor Warburton, Mr Ronald Pitts Crick, Mr Nick Rumney and the officers and council of the Royal College of Ophthalmologists for their helpful comments.

References: 1. Riad SF, Dart JKG, Cooling RJ. Primary care and ophthalmology in the United Kingdom. Br J Ophthalmol (2003); 87:493-499 General Ophthalmic Services workforce statistics. Department of Health, June 2004. Smith R, Bhagey J. Ophthalmic Medical Practitioners lost tribe or endangered species?. Royal College of Ophthalmologists 2004 (www.rcophth.ac.uk/) The Future of Ophthalmic Primary Care. Discussion paper 2004. Royal College of Ophthalmologists. Ophthalmic Primary Care as a Career. Discussion paper 2005. Royal College of Ophthalmologists.

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Author:

Richard Smith, Consultant Ophthalmologist, Stoke Mandeville Hospital, Aylesbury

May 2005 revision date May 2006