Minor eye conditions – ensuring patient centred care

RNIB is hosting a roundtable discussion,on 4 July 2017 in London,at which invited experts will consider how patients can be at the heart of considerations when developing services for minor eye conditions.

This brief is produced by RNIB resulting from a rapid review of published literature (Appendix 1 describes the methodology used) looking at evidence relating to the patient’s experience of minor eye conditions. It identifies a set of questions to focus discussion during the roundtable.The event is sponsored by Specsavers.

The brief presents evidence from a small number of evaluations of enhanced service schemes for minor eye conditions. There were notable gaps in the literature, including information about other pathways and comparative evaluations of services. Although some data was available on patient satisfaction levels, there was also a lack of information on other aspects of patient experience.

Information from this and four other roundtable discussions will be submitted to the All Party Parliamentary Group on Eye Health and Visual Impairment’s Inquiry into capacity issues in ophthalmology, and collated into a formal report as the final stage.

Context

In 1999, the General Optical Council removed the obligation to refer patients with eye disease to medical practitioners where there is no justification to do so. Subsequently, numerous Enhanced Service Schemesor Enhanced Optical Serviceswere developed, and delivered by optometrists, to treat minor eye conditions[1].

The evolution of these services has, in part, formed a response to demands onAccident and Emergency (A&E) and Emergency Eye Care. In 2016, The Royal College of Ophthalmologists (RCOphth) published The Way Forward: Emergency eye care,which discussed howdemand for emergency services is increasing[2]. For instance, Moorfields saw over 100,000 attendances in the years 2015-16:this is twice as many patients as ten years previously [2]. The increase is in line with a general rise in A&E numbers[2],which appears to be driven by shifting health seeking behaviours and the 2004 reduction of out-of-hours appointments in General Practice[2]. Devolving acute care to optometrists,as in enhanced service schemes, is therefore presented byRCOphth as one way to manage demand[2]. Enhanced primary eye care is available in community optical practice, general practice, and community health clinics[3]. The services are known variously as Primary Eye-care Acute Referral Schemes (PEARS), Acute Community Eye-care Services (ACES), and Minor Eye Conditions Services (MECS). As a variety of acronyms are used across the literature, in this briefing we use whichever term appears in the stated reference.

There is limited published data available on who experiences minor eye conditions, and how they are experienced. A study which monitored a MECS in Lambeth and Lewisham over a twelve month period counted 2307 patient visits, with 2123 patients assessed at 13 community practices[1]. The youngest patient seen was 1 year and the oldest was 93 years (median age: 47 years, IQR: 33–62 years).No data on patient gender were available. The commonest reason for a MECS assessment was ‘red eye’ (36.7 per cent of patients); other common reasons for attending were ‘painful white eye’ (11.1 per cent), ‘flashes and floaters’ (10.2 per cent) and ‘loss of vision’ (9.2 per cent), while ‘headaches’ (5.3 per cent), ‘trauma’ (1.7 per cent) and ‘diplopia’ (0.4 per cent) were less common. A quarter (25.4 per cent) of patients seen through MECS presented for reasons that did not fall under any of the predefined criteria; two-thirds of these (66.2 per cent) presented with anterior eye symptoms (e.g. dry or watery eyes, lid lumps and foreign body sensation).

What ways of deliveringcare are in place for minor eye conditions?

RCOphth interviewed 38 consultants from England and Northern Ireland in The Way Forward report. 42 per cent reported having a local acute eye-care scheme mediated through community optometrists [4]. Although alternative pathways were not specified for the remaining 58 per cent, we can infer care is delivered through a combination of GP, Emergency Eye Care and Accident and Emergency services.

The Local Optical Committee Support Unit (LOCSU) provide the following guidelines for delivering care via the MECS pathway [4]. Patients can self-refer or be referred into MECS by their GP, practice nurse, surgery receptionist, pharmacist, optometrist, A&E, or Eye Casualty. Patients can choose from a list of optometrists who must be able to offer an examination within 48 hours, excluding weekends and public holidays [4].

The MECS criteria for inclusion are[4]:

  • loss of vision including transient loss
  • sudden onset of blurred vision
  • ocular pain or discomfort
  • systemic disease affecting the eye
  • differential diagnosis of the red eye
  • foreign body and emergency contact lens removal
  • dry eye
  • epiphora
  • trichiasis
  • differential diagnosis of lumps in the vicinity of the eye
  • recent onset of diplopia
  • flashes or floaters
  • retinal lesions
  • patient reported field defects

Diabetic retinopathy, adult squints, and repeat field tests are excluded from MECS[4].

Outcomes resulting from the consultation can include[4]:

  • The optometrist managing the condition, offering the patient advice, appropriate prescriptions or recommendations for medication, and follow-up consultations if required.
  • Minor clinical procedures such as eyelash removal.
  • Diagnosis with a concomitant prescription or request to the GP to prescribe.
  • Tentative diagnosis with either an urgent or non-urgent referral into the Hospital Eye Service.
  • Reassurance and discharge.
  • The recommendation of an NHS or private sight test.

What challenges do patients experience during the enhanced services pathway for minor eye conditions?

  • Some groups are under represented among minor eye care self-referrals: One study of the Welsh Eye Care Service in 2016 found markedly greater numbers of women than men used PEARS [5]. Older age groups were also more heavily represented, possibly due to higher awareness following the eligibility for a free sight test at 60. The majority of patients were self- rather than GP-referred [5]. The under-representation of certain groups may be due to insufficiently tailored public health campaigns, leading to differences in either awareness, or reluctance to use the service [5].
  • Poor streamlining: Patients who initially present to the GP, see an optometrist on the GP’s referral, and see the GP again for their prescription experience a three visit consultation for a minor eye condition[6]. MECS optometrists supply ophthalmic medications for common eye conditions including topical antibiotics and anti-allergy drugs, but may not have specialist prescribing qualifications [6].
  • Obtaining appointments: Where patients are experiencing painful or alarming eye symptoms, they may present to eye casualty or urgent referral clinics because of limited capacity in community based alternatives to provide same-day, next-day, evening and weekend appointments [2].
  • Access: There is some evidence of a strong tendency for optometrist practices to be located outside areas of high relative deprivation. Encouraging access to services via optometrists may not increase uptake from lower socio economic groups but may have the unintended consequence of increasing uptake from less deprived groups [2].

Do patients get the same quality of care from different service pathways?

The rapid review did not identify anyevaluations which compared different pathways in terms ofpatientexperience/outcomes.

In 2016, a realist review relating to enhanced eye care services found that they were clinically effective and provided patient satisfaction [7]. Evaluations of the services varied in scope and quality; the most comprehensive found that over 70 per cent of patients who were either self- or GP-referred were managed in primary care without onward referral [7]. The majority of patients, across the studies, were seen within 48 hours. Two studies collected patients’ views on service quality, and both reported high satisfaction levels [7].

There is some further limited evidence of good levels of patient satisfaction with the delivery of MECS. Data collected for twelve months in the Lambeth and Lewisham MECs, from 109 patients, showed that 100 per cent were satisfied with their visit to the optometrist and 99 per cent would recommend the scheme to a friend[1]. 95 per cent reported confidence and trust in their MECs optometrist and 90 per cent were satisfied with the location of the practices they attended [1].

A separate study of multi-stakeholder perspectives on a MECSin Manchester found that 100 per cent of patients were satisfied with their optometrists’ examination[6]. The majority awarded ‘very good’ ratings to examination duration, optometrists’ listening skills, explanations of tests and management, patient involvement in decision making, and the treatment of the patient with care and concern[6]. Interpretations of these positive results should be undertaken in the context of the scheme being restricted to certain post code areas. High satisfaction levels may not reflect inequalities in who is able to access the service to begin with [6].

The same study collected evidence of cost-effectiveness from commissioners; however the commissioners were keen to note the greater importance of quality of care [6].

In The Way Forward report, findsmixed evidence on whether MECs reduced GP referrals to hospital eye services, and scepticism among consultants that PEARS/MECS have an impact on hospital eye service demand[2]. The report therefore concludes that there is a pressing need to evaluate how community optometry based acute eye care schemes impact on health seeking behaviours, and on ophthalmic presentations to general practice and secondary care [2].

What are the ways to ensure that patients get the best services?

The Way Forward report states that the following elements should be considered in order to develop and maintain a successful MECS [2]:

  • Address access inequalitiesto reduce the post code lottery of service provision, through service mapping and training of health care professionals
  • Sustainability planning: Increases in demand should be anticipated on the basis of attendance data, and should inform assessments of training needs/resource allocation
  • Effective engagement e.g. including GPs with special interest in ophthalmology
  • Cooperation and collaboration e.g. between Clinical Commissioning Groups, Local Optical Committee and HES
  • Efficient communication e.g. use of electronic referral schemes
  • Establishing regular training and clear protocols e.g. weekly sessions overseen by the consultant lead

Gaps in the evidence

  • Research focused on patients’ experience of developing, and receiving treatment for, minor eye conditions.
  • UK based evaluationswhich include patient experience beyond levels of satisfaction.
  • UK based studies which compare different pathways.
  • UK based studies which identify good practice and test new pathways of care.
  • Evaluation methodologies which take account of geographical and socioeconomic variation in access to services.

What do we still need to know about MECs to ensure patients get the best outcomes?

1. How can we ensure that quality and patient safety is not sacrificed to improve efficiency?

2. How can eye care professionals work together to support the development of effective minor eye conditions pathways?

3.What evidence and information do commissioners need to commission appropriate care for minor eye conditions?

Authors

Kate Flynn, Catherine Dennison and Puja Joshi. RNIB.

Appendix 1 Methodology

KF carried out the searches to identify relevant material published in, and since, 2000, using the search engines PubMed and Science Direct. The following key words were used: MECs, minor eye conditions schemes, PEARS, Primary Eye-care Assessment and Referral Service, EOS, enhanced optical services, ESS, enhanced service schemes, community eyecare schemes, ACES, Acute Community Eyecare Services,Patient*, Diagnos*, Ophthalmology, Optom*, Referral*, Consultation*, Outcome, Evaluation, and Local. 14 peer reviewed papers, reports, guidance documents and articles were identified. Reference lists were hand-searched.

KF carried out the rapid reviewing and wrote this paper, with comments from Puja Joshi, Helen Lee and Catherine Dennison.

Appendix 2 References

[1] Konstantakopoulou E, Edgar DF, Harper RA, Baker H, Sutton M, Janikoun S, Larkin G & Lawrenson JG. 2016. Evaluation of a minor eye conditions scheme delivered by community optometrists. BMJ Open; 6(8).

[2] The Royal College of Ophthalmologists. 2016 The way forward: Emergency eye care. London: The Royal College of Ophthalmologists.

[3] Hornby S. 2013. Primary care ophthalmology care. The Royal College of Ophthalmologists.

[4] Local Optical Committee Support Unit. 2008, revised 2016. Minor eye conditions service (MECS) pathway. LOC Central Support Unit.

[5]McAlinden C, Corson H, Sheen N Garwood P. 2016. Demographics, referral patterns and management of patients accessing the Welsh Eye Care Service. Eye and Vision; 3:14.

[6] Baker H, Harper RA, Edgar DF & Lawrenson JG. 2016.

Multi-stakeholder perspectives of locally commissioned enhanced optometric services. BMJ Open; 6(10).

[7]Baker H, Ratnarajan G, Harper RA, Edgar DF & Lawrenson JG. 2016. Effectiveness of UK optometric enhanced eye care services: A realist review of the literature. Ophthalmic and Physiological Optics; 36(5):545-557.

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